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17 August 2011

Emphysema-like disease and HIV

Emphysema is an incurable condition that occurs when the walls between the air sacs in the lung lose their ability to stretch and recoil, causing shortness of breath. Some HIV patients develop a condition called emphysema-like disease, which causes similar symptoms. The main difference between these two conditions is that abnormal masses in the lungs, called cystic lesions, cause symptoms of emphysema-like disease.

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BACKGROUND

Emphysema is an incurable condition that occurs when the walls between the air sacs in the lung lose their ability to stretch and recoil, causing shortness of breath. Some HIV patients develop a condition called emphysema-like disease, which causes similar symptoms. The main difference between these two conditions is that abnormal masses in the lungs, called cystic lesions, cause symptoms of emphysema-like disease.

The exact cause of these lesions in the lungs remains unknown. However, researchers believe injection-drug use (IDU), recurrent infections, and the HIV itself may contribute to the development of lesions.

Emphysema-like disease can be successfully treated. Patients who use injection drugs should discontinue using drugs in order to prevent the development of new lesions. If an infection is causing the condition, the patient will receive antimicrobials that destroy the disease-causing microorganism and prevent the development of new lesions. If it is suspected that HIV is causing the condition, patients will receive aggressive HIV treatment called highly active antiretroviral therapy (HAART).

Steroids and supplemental oxygen may help alleviate symptoms. If symptoms are severe, patients may require surgery to remove damaged lung tissue. If the lung cannot be repaired, a lung transplant may be necessary.

CAUSES

General: The cause of emphysema-like disease is not well understood. However, there is evidence that injection drug use (IDU), HIV itself, and/or lung infections may lead to the development of the condition.

Drug use: Several studies have suggested that injection-drug use (IDU), especially with intravenous use of methadone or methylphenidate (Ritalin©), may lead to the development of emphysema-like disease. Researchers believe the lung injury occurs when insoluble fillers, such as cornstarch, cotton fibers, cellulose, or talc, are injected into the blood. These fillers, which may be present in drugs that are supposed to be taken by mouth (e.g. Ritalin©), are filtered through the lungs and cause damage.

HIV: If HIV infects cells in the lungs, the virus may cause lesions that produce emphysema-like symptoms.

Lung infections: Because HIV infects and destroys the body's immune cells, HIV patients have an increased risk of developing infections, including lung infections. Lung infections, such as Pneumonitis jiroveci pneumonia (formerly called Pneumonitis carinii pneumonia or PCP), tuberculosis, and mycobacterium avium complex (MAC), may cause lesions in the lungs. These lesions may lead to symptoms similar to emphysema.

SYMPTOMS

Common symptoms of emphysema-like disease include shortness of breath and fatigue. Other symptoms may include distress resulting from the inability to get enough air, wheezing, chronic mucus production, weight loss, exhaling through pursed (puckered) lips or grunting before exhaling, needing to lean forward to breathe while sitting, anxiety (nervousness), and/or depression. If left untreated, severe shortness of breath may limit the person's ability to perform normal daily activities.

If a lung infection is causing symptoms, other symptoms such as cough, pleurisy (pain with breathing or coughing), fever, weight loss, night sweats, enlarged lymph nodes, chills, and loss of appetite may occur.

DIAGNOSIS

General: If patients have emphysema-like symptoms, a chest X-ray is performed. If lesions are detected, additional tests will be performed to determine the cause. If the patient injects illegal drugs and no bacteria or viruses (including HIV) were found in the lungs, drug use may be the cause.

Bronchoalveolar lavage: A bronchoalveolar lavage (BAL) is commonly performed to determine whether patients have lung infections. During the procedure, a thin, flexible tube called a bronchoscope is passed through the mouth or nose into the lungs. Saline (salt water solution) is then squirted into a small part of the lung and collected for analysis. If the sample contains microorganism known to cause infection, a positive diagnosis is made.

Chest X-ray: A chest x-ray can be used to detect the presence of lesions in the lung.

Open lung biopsy: An open lung biopsy is the most invasive diagnostic procedure, and it has 100% sensitivity and specificity because it provides the greatest amount of tissue for diagnosis. However, since a lung biopsy is the most invasive test, it should only be performed when all other diagnostic tests are inconclusive. The procedure is performed in a hospital while the patient is under general anesthesia. A tube will be placed through the mouth and into the airway that leads to the lungs. After cleaning the skin, the surgeon makes a cut in the chest area and removes a small piece of lung tissue. The wound is closed with stitches. A chest tube may be left in place for one to two days to prevent the lung from collapsing. The tissue sample is taken to a laboratory for analysis.

Complications are more likely to occur in patients who have lung diseases or severe breathing problems. Complications associated with open lung biopsies include infection, bleeding, collapsed lung (pneumothorax), spasms of the bronchial tubes, and irregular heartbeat.

Transbronchial biopsy: During a transbronchial biopsy, a bronchoscope is inserted through the patient's mouth or nose and into the lungs. Then, tiny forceps are inserted into the hollow tube of the bronchoscope. A small amount of lung tissue is then removed for analysis. If the sample contains microorganisms known to cause infection, a positive diagnosis is made. Patients may need to stay overnight at the hospital after the procedure is performed.

Pneumothorax, an accumulation of air between the outer lining of the lung and the chest wall that causes the lung to collapse, occurs in about two percent of transbronchial biopsies. There is also a risk of bleeding and infection after the procedure.

TREATMENT

General: Patients who use injection drugs should discontinue using drugs in order to prevent the development of new lesions. If an infection is causing the condition, the patient will receive antimicrobials that prevent the development of new lesions. If it is suspected that HIV is causing the condition, patients will receive aggressive HIV drug treatment called highly active antiretroviral therapy (HAART). Steroids and supplemental oxygen may also help alleviate symptoms. If symptoms are severe, patients may require surgery to remove damaged lung tissue.

Patients should tell their healthcare providers if they are taking any other drugs (prescription or over-the-counter), herbs, or supplements because they may interact with treatment.

Discontinuing drug use: Because injection drug use (IDU), especially with methadone or methylphenidate, has been associated with emphysema-like disease, individuals should discontinue drug use.

Addiction can be difficult to overcome without help. Rehabilitation treatment programs are available to help patients recover from addiction. Programs are tailored to specific individuals. Treatment may include group therapy, motivational interviewing, family therapy, and one-on-one counseling. Medication, such as buprenorphine (Suboxone©), may be prescribed to overcome withdrawal symptoms of opiate addictions. The duration of rehabilitation treatment usually lasts several months. However, treatment varies among individuals.

Antimicrobials: HIV patients who have lung infections receive antimicrobials, which are drugs that kill disease-causing microorganisms. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. The specific drug, dose, and duration of treatment vary depending on the type and severity of the infection.

Highly active antiretroviral therapy (HAART): If it is suspected that HIV itself is causing lesions in the lungs, patients should receive aggressive treatment with highly active antiretroviral therapy (HAART). This therapy is a combination of anti-HIV drugs called antiretrovirals. Medications from at least two different drug classes are combined. There are currently four classes of antiretrovirals: protease inhibitors (PIs), nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and fusion inhibitors. Each of these medications disrupts a different cycle of HIV's replication.

Lung transplant: If the patient has developed severe lesions that do not respond to treatment and cannot be surgically removed, a lung transplant may be needed. Usually just one lung is transplanted because the survival rate has been proven to be higher for individuals with single-lung transplants than for individuals with double-lung transplants.

Smoking cessation: Smoking cigarettes may worsen symptoms of emphysema-like disease. Therefore, patients are encouraged to stop smoking. Nicotine replacement products, including the patch (Habitrol©, Nicoderm CQ©, Nicotrol©), chewing gum (Nicorette©), lozenges (Commit©), inhalers (Nicotrol Inhaler©), nasal sprays (Nicotrol NS©), and the antidepressant bupropion (Zyban©), may help patients quit smoking. These drugs work in part by continuing to release low levels of a brain chemical called dopamine. In this way, these smoking cessation medications decrease the craving for nicotine and reduce the signs and symptoms of withdrawal.

Varenicline (Chantix©) is a new drug that works in a similar way. Chantix© stimulates the release of low levels of dopamine in the brain to help reduce the signs and symptoms of withdrawal. In addition, Chantix© blocks nicotine receptors in the brain. The U.S. Food and Drug Administration (FDA) has approved the course of Chantix© treatment for 12 weeks. Individuals who successfully quit smoking during Chantix© treatment may continue to use Chantix© for an additional 12 weeks to further increase the likelihood of long-term smoking cessation. Side effects of Chantix© include changes in taste, nausea, vomiting, gas, and insomnia (inability to sleep).

Steroids: Steroids are used to prevent and reduce airway swelling, as well as decrease the amount of mucus in the lungs. Steroids may either be inhaled with an inhaler or taken by mouth. Inhaled steroids include beclomethasone (Beclovent© and Vanceril©), budesonide (Pulmicort Respules©), flunisolide (Aerobid©), fluticasone (Flovent©), and triamcinolone (Azmacort©). Inhaled steroids seem to have fewer side effects than oral steroids. Prolonged use may weaken the bones and increase the risk of cataracts, diabetes, and heart disease, including high blood pressure, high cholesterol levels, chest pain, and heart attack.

Oral corticosteroids commonly prescribed include prednisone (Prednisone Intensol©, Sterapred©, and Sterapred© DS) and triamcinolone (Aristocort©). Liquid corticosteroids (such as Pediapred© or Prelone©) are available for children. These medications can be used short-term for severe symptoms such as extreme shortness of breath. However, these drugs are generally not recommended for long-term use because they weaken the immune system, making HIV patients even more vulnerable to diseases and infections.

Supplemental oxygen: Patients who have extreme difficulty breathing may benefit from supplement oxygen. Various forms of oxygen are available, as well as different devices to deliver them to the lungs. A healthcare provider will help the patient set up oxygen for home use.

Surgery: In a procedure called lung volume reduction surgery (LVRS), surgeons remove small pieces of damaged lung tissue. The extra space that is created in the lungs after surgery appears to help the remaining lung tissue work more efficiently.

INTEGRATIVE THERAPIES

Unclear or conflicting scientific evidence :

Acupressure, shiatsu : During acupressure, finger pressure is applied to specific acupoints on the body. A combination of acupressure and massage may reduce symptoms of labored breathing and anxiety in patients with chronic obstructive pulmonary disease who use prolonged mechanical breathing support. Further study of acupressure alone is needed before a firm conclusion can be made.

A small study of patients undergoing pulmonary (lung) rehabilitation reported acupressure to be a beneficial treatment for shortness of breath. Larger, well-designed studies are needed before clear conclusions can be drawn.

With proper training, acupressure appears to be safe if self-administered or performed by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Alexander technique : The Alexander technique is an educational program that teaches movement patterns and postures. The technique is used to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve medical conditions, and promote well-being. There is a small amount of research on the effects of the Alexander technique on lung function in healthy people and musicians who play wind instruments. These studies are small, poorly designed, and report mixed results. Until better evidence is available, it remains unclear if the Alexander technique improves lung capacity

No serious side effects have been reported with the Alexander technique. It has been suggested that the technique may be less effective in patients with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.

Belladonna : Belladonna has been used for centuries to treat many medical conditions. Belladonna may cause relaxation of the airway and reduce the amount of mucus produced. However, due to a lack of high-quality human research in this area, there is not enough evidence to form a clear conclusion.

Avoid if allergic to belladonna or plants of the Solanaceae (nightshade) family (such as bell peppers, potatoes, eggplants). Avoid with a history of heart disease, high blood pressure, heart attack, abnormal heartbeat (arrhythmia), congestive heart failure, stomach ulcer, constipation, stomach acid reflux (serious heartburn), hiatal hernia, gastrointestinal disease, ileostomy, colostomy, fever, bowel obstruction, benign prostatic hypertrophy, urinary retention, glaucoma (narrow angle), psychotic illness, Sj©gren's syndrome, dry mouth (xerostomia or salivary gland disorders), neuromuscular disorders (such as myasthenia gravis), or Down's syndrome. Avoid if pregnant or breastfeeding.

Chiropractic therapy : Chiropractic care focuses on how the relationship between musculoskeletal structure (mainly the spine) and bodily function (mainly the nervous system) affects health. There is not enough reliable scientific evidence to make a conclusion on the effects of chiropractic techniques for respiratory tract infections that cause difficulty breathing.

Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

Coleus : The root extract of coleus is known as forskolin. Coleus may be a beneficial treatment before intubation for patients with breathing disorders. However, more research is needed before a firm recommendation can be made.

Avoid if allergic or hypersensitive to coleus. Avoid with bleeding disorders or heart problems. Use cautiously with thyroid disorders, seizures disorders, or with a history of ulcers. Avoid if pregnant or breastfeeding.

English ivy : English ivy (Hedera helix) is native to most of Europe and southwest Asia. Although it is often used as a landscaping groundcover in the United States, it is also an invasive species that is considered a noxious weed in some areas. Currently, there is insufficient available information to determine whether or not English ivy is an effective treatment for chronic obstructive pulmonary disease, such as emphysema. Additional study is needed in this area.

Avoid if allergic or hypersensitive to English ivy (Hedera helix), its constituents, or members of the Araliaceae family. In addition, cross-sensitivity has been noted between Hedera helix and Dendropanax trifidus, Schefflera arboricola, dandelion (Taraxacum officinale), false ragweed (Ambrosia acanthicarpa), giant ragweed (Ambrosia trifida), short ragweed (Ambrosia artemisifolia), sagebrush (Artemisia tridentata), wild feverfew (Parthenium hysterophorus), yarrow (Achillea millifolium), tansy (Tanacetum vulgare), and some Dahlia species. Use cautiously with cancer or if taking antineoplastic (anti-cancer) agents. Avoid if pregnant or breastfeeding.

Ginseng : For more than 2,000 years, the roots of this slow-growing plant have been valued in Chinese medicine. In one study, ginseng was reported to improve lung function and exercise capacity in patients with chronic obstructive pulmonary diseases, such as emphysema. Further research is needed to confirm these results.

Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in the ginseng formulation.

Hydrotherapy : Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. There is preliminary evidence that daily breathing exercises in a warm pool may improve lung function measurements in patients with chronic obstructive pulmonary diseases, such as emphysema. It is not clear if this technique is superior to breathing exercises alone. Evidence from controlled trials is necessary before a clear conclusion can be drawn.

Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices, such as pacemakers, defibrillators, or liver infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and it should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physicians before starting hydrotherapy.

L-carnitine : Currently there is insufficient evidence to support the use of carnitine for respiratory distress in adults.

Avoid with a known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lutein : Carotenoids such as lutein and zeaxanthin are found in high levels in foods such as green vegetables, egg yolk, kiwi fruit, grapes, orange juice, zucchini, squash, and corn. Lutein has been suggested as a possible treatment to enhance lung function in patients with lung infections. However, further research is needed to determine the safety and efficacy of this treatment.

Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for heart disease or cancer. Avoid if pregnant or breastfeeding.

Nasal irrigation : Nasal irrigation is used to clear the sinuses. There are three forms of nasal irrigation therapies. Saline lavage uses a warm liquid solution (such as Rhinomer©), while large-particle nebulized aerosol therapy uses aerosolized saline solution. A humidified warm air lavage (hyperthermia) is also used. Occasionally, antibiotics are added to the solution. Nasal irrigation can be performed by the patient at home or by a professional up to twice daily. Preliminary evidence suggests that nasal irrigation may help remove mucus from the lungs, which may make it easier for the patient to breathe. Further research is warranted in this area.

Nasal irrigation is generally well tolerated. Use cautiously with a history of frequent nosebleeds. If the irrigation liquid is hot, the nose may become irritated.

Physical therapy : According to the American Physical Therapy Association, the goal of physical therapy, or physiotherapy, is to improve mobility, restore function, reduce pain, and prevent further injury. Many techniques, including exercises, stretches, traction, electrical stimulation, and massage are used. There may be a beneficial effect of respiratory rehabilitation in terms of improved tolerance to exercise and improved quality of life for patients with chronic obstructive pulmonary diseases, such as emphysema. Studies have investigated the use of physical therapy with drugs, as well as the difference between manual and mechanical techniques. Few studies have compared respiratory physiotherapy to control groups. Examples of manual respiratory physical therapy techniques include postural drainage, chest percussion, vibration, chest shaking, directed coughing, and forced exhalation technique. Higher-quality trials are needed to make a firm recommendation.

Preliminary research suggests that physical therapy may also improve lung function. However, further research is needed.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare providers before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Thymus extract : Thymus extracts for nutritional supplements are usually derived from young calves (bovine). Preliminary evidence suggests that both intramuscular and oral thymus extract may be useful for reducing the presence of respiratory tract symptoms. Additional study is need in this area.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if receiving immunosuppressants or hormonal therapy. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.

Traditional Chinese medicine : Traditional Chinese medicine (TCM) is a broad term that refers to many different treatments and traditions of healing. They share a common heritage of technique, or theory, rooted in ancient Chinese philosophy (Taoism) that dates back over 5,000 years. TCM herbs have been reported to improve symptoms and improve immune function in patients with chronic obstructive pulmonary disease, such as emphysema. However, research designs have been weak, and more studies of better design are needed before conclusions can be made.

Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

Yoga : Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga has been described as "the union of mind, body, and spirit," which addresses physical, mental, intellectual, emotional, and spiritual dimensions towards an overall harmonious state of being. Limited adult human study exists for the treatment of lung conditions. Better-designed research is necessary before any firm conclusions can be made.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of severe mental illness (psychotic disorders). Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

PREVENTION

Avoidance of respiratory infections: Avoid being around crowds during the cold and flu season (colder months). Washing the hands frequently along with carrying a small bottle of hand sanitizer helps keep viruses and bacteria away. Touching the nose or rubbing the eyes increases a patient's risk of developing viral or bacterial infections. Patients should talk to their healthcare providers about recommended vaccines.

Discontinuing drug use: Because injection drug use (IDU), especially with methadone or methylphenidate (Ritalin©), has been associated with emphysema-like disease, illicit drugs should be avoided. Patients who are taking drugs and want to stop may benefit from a rehabilitation program.

Highly active antiretroviral therapy (HAART): Since HIV may infect lung cells and lead to emphysema-like disease, patients should receive highly active antiretroviral therapy (HAART), which suppresses HIV's ability to replicate. This therapy involves combinations of different anti-HIV drugs, which are called antiretrovirals. HAART suppresses HIV, which boosts the immune system and reduces the risk of infections.

Smoking cessation: Smoking cigarettes may worsen symptoms of emphysema-like disease. Therefore, patients are encouraged to stop smoking.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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  • Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2007. Accessed June 11, 2007.
  • Sahebjami H. Emphysema-like changes in HIV. Ann Intern Med. 1992 May 15;116(10):876. View abstract
  • Tasaka S, Takagi H, Oguma T, et al. Pulmonary emphysematous changes associated with Pneumocystis carinii pneumonia in an AIDS patient. Nihon Kokyuki Gakkai Zasshi. 1998 Mar;36(3):283-7. View abstract
  • The Body: The Complete HIV/AIDS Resource. www.thebody.com. Accessed June 11, 2007.
  • Yearsley MM, Diaz PT, Knoell D, et al. Correlation of HIV-1 detection and histology in AIDS-associated emphysema. Diagn Mol Pathol. 2005 Mar;14(1):48-52. View abstract


Copyright © 2011 Natural Standard (www.naturalstandard.com)
 
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