Resources - lung disease

The following organizations are good resources for information on lung disease:

• American Lung Association - www.lungusa.org
• National Heart, Lung, and Blood Institute - www.nhlbi.nih.gov

Lung cancer is cancer that begins in the lungs, the two organs found in the chest that help you breathe.

The lungs are made up of areas called lobes. The right lung has three lobes; the left lung has two, so there's room for the heart. When you breathe, air goes through your nose, down your windpipe (trachea), and into the lungs where it spreads through tubes called bronchi. Most lung cancer begins in the cells that line these tubes.

There are two main types of lung cancer:

• Non-small cell lung cancer (NSCLC) is the most common type of lung cancer.
• Small cell lung cancer makes up about 20% of all lung cancer cases.

If the lung cancer is made up of both types, it is called mixed small cell/large cell cancer.

If the cancer started somewhere else in the body and spread to the lungs, it is called metastatic cancer to the lung.

Cancer - lung

Lung cancer is the deadliest type of cancer for both men and women. Each year, more people die of lung cancer than breast, colon, and prostate cancers combined.

Lung cancer is more common in older adults. It is rare in people under age 45.

Cigarette smoking is the leading cause of lung cancer.

The more cigarettes you smoke per day and the earlier you started smoking, the greater your risk of lung cancer. There is no evidence that smoking low-tar cigarettes lowers the risk.

However, lung cancer has occurred in people who have never smoked.

Secondhand smoke (breathing the smoke of others) increases your risk of lung cancer. According to the American Cancer Society, an estimated 3,000 non-smoking adults will die each year from lung cancer related to breathing secondhand smoke.

The following may also increase one's risk of lung cancer:

• High levels of air pollution
• High levels of arsenic in drinking water
• Radon gas
• Asbestos
• Family history of lung cancer
• Radiation therapy to the lungs
• Exposure to cancer-causing chemicals such as uranium, beryllium, vinyl chloride, nickel chromates, coal products, mustard gas, chloromethyl ethers, gasoline, and diesel exhaust

Early lung cancer may not cause any symptoms. Many times, lung cancer is found when an x-ray is done for another reason.

Symptoms depend on the specific type of cancer you have, but may include:

• Cough that doesn't go away
• Coughing up blood
• Shortness of breath
• Wheezing
• Chest pain
• Loss of appetite
• Losing weight without trying
• Fatigue

Additional symptoms that may also occur with lung cancer:

• Weakness
• Swallowing difficulty
• Nail problems
• Joint pain
• Hoarseness or changing voice
• Swelling of the face
• Facial paralysis
• Eyelid drooping
• Bone pain or tenderness

These symptoms can also be due to other, less serious conditions, so it is important to talk to your health care provider.

For more information, see:

• Small cell lung cancer
• Non-small cell lung cancer

The health care provider will perform a physical exam and ask questions about your medical history. You will be asked if you smoke, and if so, how long you have smoked.

When listening to the chest with a stethoscope, the health care provider can sometimes hear fluid around the lungs, which could (but doesn't always) suggest cancer.

Tests that may be performed include:

• Chest x-ray
• Sputum cytology test to look for cancer cells
• Blood work
• CT scan of the chest
• MRI of the chest
• Positron emission tomography (PET) scan

In some cases, the health care provider may need to remove a piece of tissue from your lungs for examination under a microscope. This is called a biopsy. There are several ways to do this:

• Bronchoscopycombined with biopsy
• Pleural biopsy
• CT scan directed needle biopsy
• Mediastinoscopy with biopsy
• Open lung biopsy

For more information, see:

• Small cell lung cancer
• Non-small cell lung cancer

Treatment depends on the specific type of lung cancer. Each type is treated differently. Chemotherapy, radiation, and surgery may be needed.

See the individual articles on the different types of lung cancer:

• Non-small cell lung cancer
• Small cell lung cancer

How well a patient does depends on the following:

• Type of lung cancer
• Whether or not the cancer has spread
• Your age
• Your overall health
• How well you respond to treatment

The earlier the cancer is found, the better the chances of survival. Lung cancer is a deadly disease. Nearly 60% of people with lung cancer die within a year. However, some people are cured and go on to live many years.

The cancer may spread to other parts of the body (metastasis). Cancer treatment can cause significant side effects.

Call your health care provider if you develop symptoms of lung cancer (particularly if you smoke).

If you smoke, quit. It is never too late to stop smoking. You should also avoid breathing in the smoke from other people's cigarettes, cigars, or pipes.

Eating a diet rich in fruits and vegetables may help prevent some cases of lung cancer.

Alberg AJ, Ford JG, Samet JM; American College of Chest Physicians. Epidemiology of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:29S-55S.

Bach PB, Silvestri GA, Hanger M, Jett JR. Screening for lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:69S-77S.

National Cancer Institute. Lung Cancer Home Page. Bethesda, MD: U.S. National Institutes of Health. Accessed August 3, 2008

Jett JR, Schild SE, Keith RL, Kesler KA. Treatment of non-small cell lung cancer, stage IIIB: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:266S-276S.

Johnson DH, Blot WJ, Carbone DP, et al. Cancer of the lung_ Non-small cell lung cancer and small cell lung cancer. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG. Clinical Oncology. 4th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2008:chap 76.

Lung disease is any disease or disorder that occurs in the lungs or that causes the lungs to not work properly. There are three main types of lung disease:

1. Airway diseases -- These diseases affect the tubes (airways) that carry oxygen and other gases into and out of the lungs. These diseases cause a narrowing or blockage of the airways. They include asthma, emphysema, and chronic bronchitis. People with airway diseases sometimes describe the feeling as "trying to breathe out through a straw."
2. Lung tissue diseases -- These diseases affect the structure of the lung tissue. Scarring or inflammation of the tissue makes the lungs unable to expand fully ("restrictive lung disease"). It also makes the lungs less capable of taking up oxygen (oxygenation) and releasing carbon dioxide. Pulmonary fibrosis and sarcoidosis are examples of lung tissue diseases. People sometimes describe the feeling as "wearing a too-tight sweater or vest" that won't allow them to take a deep breath.
3. Pulmonary circulation diseases -- These diseases affect the blood vessels in the lungs. They are caused by clotting, scarring, or inflammation of the blood vessels. They affect the ability of the lungs to take up oxygen and to release carbon dioxide. These diseases may also affect heart function.

Most lung diseases actually involve a combination of these categories.

The most common lung diseases include:

• Asthma
• Chronic bronchitis
• COPD (chronic obstructive pulmonary disease)
• Emphysema
• Pulmonary fibrosis
• Sarcoidosis

Other lung diseases include:

• Asbestosis
• Aspergilloma
• Aspergillosis
• Aspergillosis - acute invasive
• Atelectasis
• Eosinophilic pneumonia
• Lung cancer
• Metastatic lung cancer
• Necrotizing pneumonia
• Pleural effusion
• Pneumoconiosis
• Pneumocystosis
• Pneumonia
• Pneumonia in immunodeficient patient
• Pneumothorax
• Pulmonary actinomycosis
• Pulmonary alveolar proteinosis
• Pulmonary anthrax
• Pulmonary arteriovenous malformation
• Pulmonary edema
• Pulmonary embolus
• Pulmonary histiocytosis X (eosinophilic granuloma)
• Pulmonary hypertension
• Pulmonary nocardiosis
• Pulmonary tuberculosis
• Pulmonary veno-occlusive disease
• Rheumatoid lung disease

Lung transplant is surgery to replace one or both diseased lungs with healthy lungs from a human donor.

Solid organ transplant - lung

The new lung or lungs are usually donated by someone who has been declared brain-dead but remains on life-support. The donor tissue must be matched as closely as possible to your tissue type to reduce the odds that your body will reject the transplanted lung.

Lungs can also be given by living donors. Two or more people are needed. Each donates a section (lobe) of their lung to form an entire lung for the person receiving it.

During lung transplant surgery, you are unconscious and pain-free (under general anesthesia). A surgical cut is made in the chest.

• For single lung transplants, the cut is made on the side of your chest that will be receiving the lung. The operation takes 4 - 8 hours.
• For double lung transplants, the cut is made below the breast. Surgery generally takes 6 - 12 hours. Tubes are used to reroute blood to a heart-lung bypass machine to provide oxygen and move blood through the body during the surgery.

After the cut is made, the major steps during lung transplant surgery include:

• One or both of your lungs are removed. For those receiving a double lung transplant, most or all of the steps from the first transplant are completed before the second transplant is done.
• The main blood vessels and airway of the new lung are sewn to your main blood vessel and airway. The donor lung or lungs are stitched (sutured) into place. Chest tubes are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.

Sometimes heart and lung transplants are done at the same time (heart-lung transplant) if the heart is also diseased.

A lung transplant is usually the last-resort treatment for lung failure. Lung transplants may be recommended for patients with any severe lung disease. Some examples of diseases that may require a lung transplant are:

• Cystic fibrosis
• Emphysema
• Idiopathic pulmonary fibrosis
• Pulmonary hypertension
• Sarcoidosis
• Damage to the arteries of the lung because of a defect present at birth (congenital defect)

Lung transplant is not recommended for:

• Patients who are too sick to go through the procedure
• Patients whose lung disease will likely affect the new lung
• Patients who have severe disease of other organs

Risks for any anesthesia are:

• Breathing problems
• Reactions to the medications

Risks for any surgery are:

• Bleeding
• Infection

Other risks of transplant include:

• Blood clots (deep venous thrombosis)
• Increased risk for infections due to anti-rejection (immunosuppression) medications
• Damage to your kidneys, liver, or other body organs from immunosuppression medications

Before the procedure is done, your doctor will determine whether you are a good candidate by performing the following tests:

• Blood typing
• Tissue typing, to help make sure your body will not reject the donated lung
• Blood tests or skin tests to check for infections
• Tests to evaluate your lungs
• Tests to evaluate your heart, such as EKG, echocardiogram, or cardiac catheterization
• Tests to look for early cancer

If your transplant team believes that you are a good candidate for lung transplantation, you will be put on a national waiting list. Your place on the waiting list is based on a number of factors. Key factors include:

• What type of lung problems you have
• The severity of your lung disease
• The likelihood that a transplant will be successful

The amount of time you spend on a waiting list usually does not determine how soon you get a lung, except possibly with children. Waiting time is often at least 2 - 3 years.

While you are waiting for a new lung, follow these guidelines:

• Follow any diet your lung transplant team recommends. Stop drinking alcohol, do not smoke, and keep your weight in the recommended range.
• Take all medicines as they were prescribed. Report changes in your medications and any new or worsening medical problems to the transplant team.
• Follow any exercise program that you were taught during pulmonary rehabilitation.
• Keep any appointments that you have made with your regular doctor and transplant team.
• Let the transplant team know how to contact you immediately if a lung becomes available. Make sure that, no matter where you go, you can be contacted quickly and easily.
• Be prepared in advance to go to the hospital.

Before the procedure, always tell your doctor or nurse:

• What drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription.
• If you have been drinking a lot of alcohol (more than one or two drinks a day)

Do not eat or drink anything after midnight the night before your surgery. Take only the drugs that your doctor told you to take with a small sip of water.

You should expect to stay in the hospital for 7 - 21 days after a lung transplant. You will likely spend time in the intensive care unit (ICU) right after surgery.

During your hospital stay, you will:

• Be asked to sit on the side of the bed and then walk on the same day you have surgery
• Have a tube coming out of the side of your chest to drain fluids
• Wear special stockings on your feet and legs to prevent blood clots
• Receive shots to prevent blood clots
• Receive pain medicine through a tube that goes into your vein (IV) or by mouth with pills. You may receive your pain medicine through a special machine that gives you a dose of pain medicine when you push a button. This allows you to control how much pain medicine you receive.
• Be asked to do a lot of deep breathing to help prevent pneumonia and infection, and to inflate the lung that was transplanted. Your chest tube will stay in place until your lung has fully inflated.

The recovery period is about 6 months. Often, your transplant team will ask you to stay fairly close to the hospital for the first 3 months. You will need to have regular check-ups with blood tests and x-rays for many years.

A lung transplant is a major procedure performed for patients with life-threatening lung disease or damage. Around four out of five people are still alive 1 year after the transplant. Around two out of five transplant recipients are alive at 5 years. Outcomes are similar for single and double lung transplants.

Fighting rejection is an ongoing process. The body's immune system considers the transplanted organ as an invader (much like an infection) and may attack it.

To prevent rejection, organ transplant patients must take anti-rejection (immunosuppression) drugs (such as cyclosporine and corticosteroids). These drugs suppress the body's immune response and reduce the chance of rejection. As a result, however, these drugs also reduce the body's natural ability to fight off infections.

Smythe WR, Reznik Si, Putnam JB Jr. Lung (including pulmonary embolism and thoracic outlet syndrome). In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 59.

Davis SQ, Garrity ER Jr. Organ allocation in lung transplant. Chest. 2007;132:1646-1651.

Aurora P, Carby M, Sweet S. Selection of cystic fibrosis patients for lung transplantation. Curr Opin Pulm Med. 2008;14:589-594.

Maurer JR, Zamel N. Lung transplantation. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA, eds. Murray & Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier;2005:chap 89.

Cancer - lung - non-small cell; Non-small cell lung cancer; NSCLC; Adenocarcinoma - lung; Squamous cell carcinoma - lung

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. It usually grows and spreads more slowly than small cell lung cancer.

There are three forms of NSCLC:

• Adenocarcinomas are often found in an outer area of the lung.
• Squamous cell carcinomas are usually found in the center of the lung by an air tube (bronchus).
• Large cell carcinomas can occur in any part of the lung. They tend to grow and spread faster than the other two types.

Smoking causes most cases of lung cancer. The risk depends upon the number of cigarettes smoked every day and for how long someone has smoked. Being around the smoke from others (secondhand smoke) also raises your risk for lung cancer. However, people who do not smoke and have never smoked have become sick with lung cancer.

A review of decades of research has recently shown that smoking marijuana may help cancer cells grow, but there is no direct link between the drug and developing lung cancer.

High levels of air pollution and drinking water containing high levels of arsenic can increase your risk for lung cancer. Radiation therapy to the lungs can also increase the risk.

Working with or near the following cancer-causing chemicals or materials can also increase your risk:

• Asbestos
• Products using chloride and formaldehyde
• Certain alloys, paints, pigments, and preservatives

Early lung cancer may not cause any symptoms. Symptoms you should watch for include:

• Cough that doesn't go away
• Coughing up blood
• Shortness of breath
• Wheezing
• Chest pain
• Loss of appetite
• Losing weight without trying
• Fatigue

Other symptoms that may be due to NSCLC:

• Weakness
• Swallowing difficulty
• Nail problems
• Joint pain
• Hoarseness or changing voice
• Swelling of the face
• Eyelid drooping
• Bone pain or tenderness
• Shoulder pain or weakness

Note: These symptoms can be due to other, less serious conditions. It is important to talk to your health care provider.

The health care provider will perform a physical exam and ask questions about your medical history. You will be asked if you smoke, and if so, how long you have smoked.

When listening to the chest with a stethoscope, the health care provider can sometimes hear fluid around the lungs, which could (but doesn't always) suggest cancer.

Tests that may be performed to diagnose lung cancer or see if it has spread include:

• Chest x-ray
• CBC
• Sputum test to look for cancer cells
• Bone scan
• CT scan of the chest
• MRI of the chest
• Positron emission tomography (PET) scan
• Thoracentesis

In some cases, the health care provider may need to remove a piece of tissue from your lungs for examination under a microscope. This is called a biopsy. There are several ways to do this:

• Bronchoscopycombined with biopsy
• Pleural biopsy
• CT scan directed needle biopsy
• Mediastinoscopy with biopsy
• Open lung biopsy
• Endoscopic esophageal ultrasound (EUS) with biopsy

If the biopsy reveals you do have lung cancer, more imaging tests will be done to determine the stage of the cancer. Stage means how big the tumor is and how far it's spread. Non-small cell lung cancer is divided into five stages:

• Stage 0 - the cancer has not spread beyond the inner lining of the lung
• Stage I - the cancer is small and hasn't spread to the lymph nodes
• Stage II - the cancer has spread to some lymph nodes near the original tumor
• Stage III - the cancer has spread to nearby tissue or spread to far away lymph nodes
• Stage IV - the cancer has spread to other organs of the body such as the other lung, brain, or liver

There are many different types of treatment for non-small cell lung cancer. Treatment depends upon the stage of the cancer.

Surgery is the often the first line of treatment for patients with non-small cell lung cancer that has not spread beyond nearby lymph nodes. The surgeon may remove:

• One of the lobes of the lung (lobectomy)
• Only a small part of the lung (wedge or segment removal)
• The entire lung (pneumonectomy)

Some patients need chemotherapy. Chemotherapy uses drugs to kill cancer cells and stop new ones from growing.

• Chemotherapy alone is often used when the cancer has spread (stage IV).
• It may also be given before surgery or radiation to make those treatments more effective.
• It may be given after surgery (called adjuvant therapy) to kill any remaining microscopic areas of cancer.

Radiation therapy uses powerful x-rays or other forms of radiation to kill cancer cells. Radiation therapy can be used with chemotherapy if surgery is not possible.

The following treatments are mostly used to relieve symptoms caused by NSCLC:

• Laser therapy - a small beam of light burns and kills cancer cells
• Photodynamic therapy - uses a light to activate a drug in the body, which kills cancer cells

For additional information and resources, see cancer support group.

The outlook varies widely. Most often, NSCLC develops slowly and causes few or no symptoms until very late stages. However, in some cases, it can be extremely agressive and cause rapid death. The cancer may spread to other parts of the body, including the bone, liver, small intestine, and brain.

Chemotherapy has been shown to prolong the life and improve the quality of life in some patients with stage IV NSCLC.

Cure rates are related to the stage of disease and whether you are able to have surgery.

• Stage I and II cancer can be cured with surgery, sometimes in more than 50% of cases.
• Stage III tumors can be cured in some cases, but cure rates are much lower than earlier stage NSCLC
• Patients with stage IV disease are almost never cured, and the goals of therapy are to extend and improve the quality of their life.

• Spread of disease beyond the lung
• Side effects of surgery, chemotherapy, or radiation therapy

If you smoke, stop smoking. It's never too early to quit. People who have smoked in the past can be at increased risk for lung cancer more than 20 years after quitting, although the risk drops significantly in the first year after quitting. There are benefits to quitting smoking, even for people who are well into middle age.

Try to avoid secondhand smoke.

Eat a diet rich in fruits and vegetables.

Routine screening for lung cancer is not recommended. Many studies have been done to look at the idea, but scientists have concluded that, at this time, screening does not help improve a person's chance for a cure.

Alberg AJ, Ford JG, Samet JM; American College of Chest Physicians. Epidemiology of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:29S-55S.

American Cancer Society. Cancer Facts and Figures 2008.Atlanta, Ga: American Cancer Society; 2008.

Bach PB, Silvestri GA, Hanger M, Jett JR. Screening for lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:69S-77S.

National Cancer Institute. Lung Cancer Home Page. Bethesda, MD: U.S. National Institutes of Health. Accessed August 3, 2008

Jett JR, Schild SE, Keith RL, Kesler KA. Treatment of non-small cell lung cancer, stage IIIB: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:266S-276S.

Johnson DH, Blot WJ, Carbone DP, et al. Cancer of the lung_ Non-small cell lung cancer and small cell lung cancer. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG. Clinical Oncology. 4th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2008:chap 76.

Fischer B, Lassen U, Mortensen J, Larsen S, Loft A, Bertelsen A, Ravn J, Clementsen P, Hogholm A, Larsen K, Rasmussen T, Keiding S, Dirksen A, Gerke O, Skov B, Steffensen I, Hansen H, Vilmann P, Jacobsen G, Backer V, Maltbaek N, Pedersen J, Madsen H, Nielsen H, Hojgaard L. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med. 2009 Jul 2;361(1):32-9.

Tassinari D, Scarpi E, Sartori S, Tamburini E, Santelmo C, Tombesi P, Lazzari-Agli L. Second-line treatments in non-small cell lung cancer. A systematic review of literature and metaanalysis of randomized clinical trials. Chest. 2009 Jun;135(6):1596-609.

A lung needle biopsy is a method to remove a piece of lung tissue for examination.

Transthoracic needle aspiration; Percutaneous needle aspiration

A chest x-ray or chest CT scan may be used to find the exact spot for the biopsy. If the biopsy is done using a CT scan, you may be lying down during the exam.

A needle biopsy of the lung may also be performed during bronchoscopy or mediastinoscopy.

You sit with your arms resting forward on a table. You should try to keep still and not cough during the biopsy. The doctor will ask you to hold your breath. The skin is scrubbed and a local pain-killing medicine (anesthetic) is injected.

The physician will make a small (about 1/8-inch) cut in the skin, and will insert the biopsy needle into the abnormal tissue, tumor, or lung tissue. A small piece of tissue is removed with the needle and sent to a laboratory for examination.

When the biopsy is done, pressure is placed over the site. Once bleeding has stopped, a bandage is applied.

A chest x-ray is taken immediately after the biopsy.

The procedure usually takes 30 - 60 minutes. Laboratory analysis usually takes a few days.

You should not eat for 6 - 12 hours before the test. Your health care provider may tell you to avoid aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or blood thinners such as warfarin for a period of time before the procedure. Always check with your health care provider before changing or stopping any medications.

Before a needle biopsy of the lung, a chest x-ray or chest CT scan may be performed. Sometimes, you will be given a mild sedative before the biopsy to relax you. You must sign a consent form. It is important to remain as still as possible for the biopsy and avoid coughing.

You will receive an injection of anesthetic before the biopsy. This injection will sting for a moment. You will feel pressure and a brief, sharp pain when the needle touches the lung.

A needle lung biopsy is performed when there is an abnormal condition near the surface of the lung, in the lung itself, or on the chest wall.

The test is usually done to diagnose large abnormalities seen on chest x-ray or CT scan. Most often, the abnormality cannot be seen by other diagnostic techniques, such as bronchoscopy.

In a normal test, the tissues are normal and there is no growth of bacteria, viruses, or fungi if a culture is performed.

• Bacterial, viral, or fungal lung infection
• Cancerous cells (lung cancer, mesothelioma)
• Immune disorder
• Pneumonia

The test may also be performed for:

• Metastatic cancer to the lung
• Pneumonia with lung abscess

In a very small percentage of needle biopsies, a collapsed lung or pneumothorax occurs. Usually, chest x-rays will be done. However, if the pneumothorax is large, a chest tube may need to be inserted to expand (decompress) the lung.

In rare cases, pneumothorax can be life threatening if air escapes from the lung, gets trapped in the chest, and presses on (compresses) the lungs and heart.

Whenever a biopsy is done, there is a risk of excess bleeding (hemorrhage). Some bleeding is common, and a health care provider will monitor the amount of bleeding. Rarely, major and life-threatening bleeding may occur.

A needle biopsy should NOT be performed if other tests show that you have:

• Blood coagulation disorder of any type
• Bullae (enlarged alveoli that occur with emphysema)
• Cor pulmonale
• Cysts
• Pulmonary hypertension
• Severe hypoxia

Signs of a collapsed lung include:

• Blueness of the skin
• Rapid heart rate (rapid pulse)
• Shortness of breath

If any of these occur, report them to your health care provider immediately.

The lungs, which reside in the thorax, or chest cavity, act as a site for oxygen and carbon dioxide exchange for the blood.

Lung transplants may be recommended for patients with severe lung disease such as:

• permanent enlargement of air sacs (alveoli) with loss of ability to completely exhale (emphysema)
• hereditary lung blockages (cystic fibrosis)
• long-term (chronic) infections (sarcoidosis)
• permanent scarring and thickening of lung tissue (idiopathic pulmonary fibrosis)

While the patient is deep asleep and pain-free (general anesthesia), an incision is made through the breast bone (sternum). One or two donor lungs are transplanted, depending on the diease process being treated.

Tubes are used to re-route the blood to a heart-lung bypass machine to keep the blood oxygenated and circulating during the surgery.

The patient's lungs are removed and the donor lungs are stitched into place. Drainage tubes (chest tubes) are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.

The patient's lungs are removed and the donor lungs are stitched into place. Drainage tubes (chest tubes) are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.

Patients will require immunosupressive mediccations for the rest of their lives to prevent immune rejection of the transplanted lung. Lung transplantation results vary depending on the disease being treated and the experience of the center performing the surgery.

Review Date: 05/04/2011

Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Small cell lung cancer (SCLC) is a fast-growing type of lung cancer. It spreads much more quickly than non-small cell lung cancer.

There are three different types of small cell lung cancer:

• Small cell carcinoma (oat cell cancer)
• Mixed small cell/large cell carcinoma
• Combined small cell carcinoma

Most small cell lung cancers are the oat cell type.

Cancer - lung - small cell; Small cell lung cancer; SCLC

About 15% of all lung cancer cases are small cell lung cancer. Small cell lung cancer is slightly more common in men than women.

Almost all cases of SCLC are due to cigarette smoking. SCLC is rare in those who have never smoked.

SCLC is the most aggressive form of lung cancer. It usually starts in the breathing tubes (bronchi) in the center of the chest. Although the cancer cells are small, they grow very quickly and create large tumors. These tumors often spread rapidly (metastasize) to other parts of the body, including the brain, liver, and bone.

• Bloody sputum(phlegm)
• Chest pain
• Cough
• Loss of appetite
• Shortness of breath
• Weight loss
• Wheezing

Other symptoms that may occur with this disease:

• Facial swelling
• Fever
• Hoarseness or changing voice
• Swallowing difficulty
• Weakness

Your health care provider will perform a physical exam and ask questions about your medical history. You will be asked whether you smoke, and if so, how much and for how long you have smoked.

When listening to your chest with a stethoscope, your health care provider can sometimes hear fluid around the lungs or areas of partial lung collapse. Each of these findings could (but does not always) suggest cancer.

Small cell lung cancer has usually spread to other parts of your body by the time it is diagnosed.

Tests that may be performed include:

• Bone scan
• Chest x-ray
• Complete blood count (CBC)
• CT scan
• Liver function tests
• MRI
• Positron emission tomography (PET) scan
• Sputum test(cytology, looking for cancer cells)
• Thoracentesis(removal of fluid from the chest cavity around the lungs)

In some cases, your health care provider may need to remove a piece of tissue from your lungs for examination under a microscope. This is called a biopsy. There are several ways to do this:

• Bronchoscopycombined with biopsy
• CT scan-directed needle biopsy
• Endoscopic esophageal ultrasound (EUS) with biopsy
• Mediastinoscopy with biopsy
• Open lung biopsy
• Pleural biopsy

Usually, if a biopsy reveals cancer, more imaging tests are done to find out the stage of the cancer. (Stage means how big the tumor is and how far it has spread.) However, the traditional staging system, which uses numbers to tell how advanced the cancer is, is usually not used for patients with SCLC. Instead, SCLC is classified as either:

• Limited (cancer is only in the chest and can be treated with radiation therapy)
• Extensive (cancer has spread outside the chest)

The majority of cases are extensive.

Because SCLC spreads quickly throughout the body, treatment must include cancer-killing drugs (chemotherapy) taken by mouth or injected into the body.

• Chemotherapy may be combined with radiation therapy of the lungs in people who have limited disease.
• The most commonly used drugs in the U.S. are etoposide with either cisplatin or carboplatin.

Because the disease has usually spread by the time it is diagnosed, very few patients with SCLC are helped by having surgery. Surgery is only considered when there is only one tumor that has not spread. Chemotherapy or radiation will be needed after surgery.

Combination chemotherapy and radiation treatment is given to people with extensive SCLC. However, the treatment only helps relieve symptoms. It does not cure the disease.

Often, SCLC may have already spread to the brain, even when there are no symptoms or other signs of cancer in the brain. As a result, radiation therapy to the brain may be given to some patients with smaller cancers, or to those who had a good response in the first round of chemotherapy. This method is called prophylactic cranial irradiation (PCI).

For additional information and resources, see cancer support group.

How well you do depends on how much the lung cancer has spread.

Without treatment, the average survival is 2 -4 months. Treatment can often prolong life to 6 - 12 months in patients with extensive disease. About 10% of patients with limited spread will show no evidence of cancer at 2 years.

This type of cancer is very deadly. Only about 6% of people with this type of cancer are still alive 5 years after diagnosis.

• Cancer spreads to other parts of the body
• Side effects of surgery, chemotherapy, or radiation therapy

Call your health care provider if you have symptoms of lung cancer (particularly if you smoke).

If you smoke, stop smoking. It's never too late to quit. In addition, you should try to avoid secondhand smoke.

Routine screening for lung cancer is not recommended. Many studies have been done to look at this idea, but physicians have concluded that, at this time, screening would not help improve a person's chance for a cure.

Ettinger DS. Lung cancer and other pulmonary neoplasms. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 201.

National Cancer Institute. Small cell lung cancer treatment PDQ. Updated February 13, 2009.

U.S. Preventive Services Task Force. Lung cancer screening. Ann Int Med. 2004;140:738-739.

Lung surgery is surgery to repair or remove lung tissue. Several common lung surgeries are:

• Lobectomy, to remove one or more lobes of a lung
• Wedge resection, to remove part of a lobe in a lung
• Pneumonectomy, to remove a lung
• Surgery to remove an infection or blood in the chest cavity
• Surgery to remove small balloon-like tissues (blebs) that cause lung collapse (pneumothorax)
• Biopsy of an unknown growth

A thoracotomy is a surgical cut that a surgeon makes to open the chest wall.

See also:

• Bronchoscopy
• Esophagectomy
• Lung biopsy
• Lung transplant

Thoracotomy; Lung tissue removal; Pneumonectomy; Lobectomy; Lung biopsy; Thoracoscopy; Video-assisted thoracoscopic surgery; VATS

You will receive general anesthesia before surgery. You will be asleep and unable to feel pain. Two common ways to do surgery on your lungs are thoracotomy and video-assisted thoracoscopic surgery (VATS).

Lung surgery using a thoracotomy is called open surgery. In this surgery:

• You will lie on your side on an operating table. Your arm will be placed above your head.
• Your surgeon will make a surgical cut between two ribs. The cut will go from the front of your chest wall to your back, passing just underneath the armpit. These ribs will be separated.
• Your lung on this side will be deflated so that air will not move in and out of it during surgery. this makes it easier for the surgeon to operate on the lung.
• Your surgeon may not know how much of your lung needs to be removed until your chest is open and the lung can be seen.
• Your surgeon may also remove lymph nodes in this area.
• After surgery, one or more tubes will be placed into your chest area to drain out fluids that build up. These tubes are called chest tubes.
• After the surgery on your lungs, your surgeon will close the ribs, muscles, and skin with sutures.
• Open lung surgery may take from 2 to 6 hours.

Video-assisted thoracoscopic surgery:

• Your surgeon will make several small surgical cuts over your chest wall. A videoscope (a tube with a tiny camera on the end) and other small tools will be passed through these cuts.
• Then, your surgeon may remove part or all of your lung, drain fluid or blood that has built up, or do other procedures.
• One or more tubes will be placed into your chest to drain out fluids that build up.

Thoracotomy or video-assisted thoracoscopic surgery may be done to:

• Remove cancer(such as lung cancer)
• Treat injuries that cause lung tissue to collapse (pneumothorax or hemothorax)
• Treat permanently collapsed lung tissue (atelectasis)
• Remove lung tissue that is diseased or damaged from emphysema or bronchiectasis
• Remove blood or blood clots (hemothorax)
• Remove tumors, such as solitary pulmonary nodule
• Inflate lung tissue that has collapsed because of disease or an accident
• Remove infection in the chest cavity
• Stop fluid buildup in the chest cavity (pleurodesis)
• Biopsy an unknown growth
• Remove a blood clot from the pulmonary artery (pulmonary embolism)

Video-assisted thoracoscopic surgery can be used to treat many of these conditions. However, sometimes video surgery may not be possible, and the surgeon may have to switch to an open surgery.

Risks for any anesthesia include:

• Allergic reactions to medicines
• Breathing problems

Risks for any surgery include:

• Bleeding
• Blood clots in the legs that may travel to the lungs
• Heart attack or stroke during surgery
• Infection, including in the incision, lungs, bladder or kidney

Risks of this surgery include:

• Failure of the lung to expand
• Injury to the lungs or blood vessels
• Need for a chest tube after surgery
• Pain
• Prolonged air leak
• Repeated fluid buildup in the chest cavity

You will have several visits with your physician and undergo medical tests before you have surgery. Your doctor will:

• Do a complete physical exam
• Make sure other medical conditions you may have, such as diabetes, high blood pressure, or heart or lung problems, are under control

If you are a smoker, you should stop smoking several weeks before your surgery. Ask your doctor or nurse for help.

Always tell your doctor or nurse:

• What drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription
• If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day

During the week before your surgery:

• You may be asked to stop taking drugs that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), clopidogrel (Plavix), or ticlopidine (Ticlid).
• Ask your doctor which drugs you should still take on the day of your surgery.
• Prepare your home for your return from the hospital.

On the day of your surgery:

• Do not eat or drink anything after midnight the night before your surgery.
• Take the medications your doctor prescribed with small sips of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

Most people stay in the hospital for 5 to 7 days for open thoracotomy and 1 to 3 days after video-assisted thoracoscopic surgery. You may spend time in the intensive care unit (ICU) after either surgery.

During your hospital stay, you will:

• Be asked to sit on the side of the bed and walk as soon as possible after surgery
• Have tube(s) coming out of the side of your chest to drain fluids
• Wear special stockings on your feet and legs to prevent blood clots
• Receive shots to prevent blood clots
• Receive pain medicine through an IV (a tube that goes into your veins) or by mouth with pills. You may receive your pain medicine through a special machine that gives you a dose of pain medicine when you push a button. This allows you to control how much pain medicine you get.
• Be asked to do a lot of deep breathing to help prevent pneumonia and infection. Deep breathing exercises also help inflate the lung that was operated on. Your chest tube(s) will remain in place until your lung has fully inflated.

The outcome depends on the type of problem being treated, how much of the lung is removed, and your overall health before surgery.

Smythe WR, Reznik SI, Putnam JB Jr. Lung (including pulmonary embolism and thoracic outlet syndrome). In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 59.

Wiener-Kronish JP, Shepherd KE, Bapoje SR, Albert RK. Preoperative evaluation. In: Mason RJ, Broaddus C, Martin T, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier;2010:chap 26.

Lung diffusion testing measures how well the lungs exchange gases. This is an important part of lung testing, because the major function of the lungs is to allow oxygen to "diffuse" or pass into the blood from the lungs, and to allow carbon dioxide to "diffuse" from the blood into the lungs.

Diffusing capacity; DLCO test

You breathe in (inhale) air containing a very small amount of a tracer gas, such as carbon monoxide. You hold your breath for 10 seconds, then rapidly blow it out (exhale). The exhaled gas is tested to determine how much of the tracer gas was absorbed during the breath.

• Do not eat a heavy meal before the test.
• Do not smoke for at least 4 - 6 hours before the test.
• If you use a bronchodilator or inhaler medications, ask your health care provider whether or not you can use them before the test.

The mouthpiece fits tightly around your mouth. Clips are put on the nose.

The test is used to diagnose certain lung diseases, and in persons with established lung disease. Repeatedly measuring the diffusing capacity can help determine whether the disease is improving or getting worse.

Normal test results depend on a person's:

• Age
• Gender
• Height
• Hemoglobin (the protein in red blood cells that carries oxygen) level

Abnormal results mean that gases do not move normally across the lung tissues into the blood vessels of the lung. This may be due to lung diseases such as:

• Emphysema
• Interstitial fibrosis
• Pulmonary hypertension
• Sarcoidosis

There are no significant risks.

Other pulmonary function tests may be done together with this test.

Reynolds HY. Respiratory structure and function: mechanisms and testing. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 85.

Vital capacity is the maximum amount of air a person can expel from the lungs after a maximum inspiration. It is equal to the inspiratory reserve volume plus the tidal volume plus the expiratory reserve volume.

A person's vital capacity can be measured by a spirometer which can be a wet or regular Spirometry. In combination with other Physiologicalmeasurements, the vital capacity can help make a diagnosis of underlying lung disease. The unit that is used to determine this vital capacity is millilitres (ml).

A normal adult has a vital capacity between 3 and 5 litres. After the age of 20 the vitalcapacity decreases approximatley 250 cc per ten years.

Lung plethysmography is a test used to measure how much air you can hold in your lungs.

See also:

• Limb plethysmography
• Plethysmography

Pulmonary plethysmography; Static lung volume determination; Whole-body plethysmography

You will sit in a small, airtight room known as a body box. You will breathe or pant against a mouthpiece. Clips will be put on your nose to shut off your nostrils. Depending on the information your doctor is looking for, the mouthpiece may be open at first, and then closed.

You will be breathing against the mouthpiece in both the open and closed positions - they give different information to the doctors. As your chest moves while you breathe or pant, it changes the pressure and amount of air in the room and against the mouthpiece. From these changes, the doctor can get an accurate measure of the amount of air in your lungs.

Depending on the purpose of the test, you may be given some medication before the test.

Let your doctor know if you are taking any medications, especially ones for breathing problems. You may have to temporarily stop taking certain medications before the test.

Wear loose clothes that allow you to breathe comfortably.

Avoid smoking and heavy exercise for 6 hours before the test.

Avoid heavy meals before the test. They can affect your ability to take deep breaths.

The test involves rapid and normal breathing, and should not be painful. However, you may feel short of breath or light-headed. You will be monitored at all times by a technician.

The mouthpiece may feel uncomfortable against your mouth.

The test is done to see how well your lungs work. It can help your doctor determine if a lung problem is due to damage to the lung structure, or a loss of the lungs' ability to expand (get bigger as air flows in).

Normal values depend on your age, height, ethnic background, and gender. Normal results are given as a percentage.

Abnormal results point to a problem in the lungs. This problem can be due to a breakdown of the lung structure, or an inability of the lungs to expand.

Lung plethysmography will not find the cause of the problem. However, it will help the doctor narrow down the list of possible problems.

• Dizziness
• Light-headedness
• Shortness of breath

Gold WM. Pulmonary function testing. In: Mason RJ, Murray J, Broaddus VC, Nadel J, eds. Textbook of Respiratory Medicine. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 24.

Wagers SS, Jaffe EF, Irvin CG. Development, structure, and physiology in normal and asthmatic lung. In: Adkinson NF Jr., ed. Middleton's Allergy: Principles and Practice. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2003:chap 44.

A lung positron emission tomography (PET) scan is an imaging test that uses a radioactive substance (called a tracer) to look for disease in the lungs, especially lung cancer.

Unlike magnetic resonance imaging (MRI) and computed tomography (CT) scans, which reveal the structure of the lungs, a PET scan shows how well the lungs and their tissues are working.

See also:

• Chest MRI
• Lung cancer
• Lung gallium scan
• Solitary pulmonary nodule
• Thoracic CT

Chest PET scan; Lung nuclear medicine scan; Lung positron emission tomography; PET - chest; PET - lung; PET - tumor imaging

The health care provider will inject a small amount of a radioactive material into one of your veins, usually on the inside of the elbow. The substance travels through the blood and collects in the tissues of the lungs.

You will be asked to wait nearby as the radioactive substance is absorbed by your body. This usually takes about 1 hour.

Then, you will lie down on a table that slides into a tunnel-shaped hole in the center of the PET scanner.

The PET machine detects energy given off by the radioactive substance and changes it into 3-dimensional pictures. The images are sent to a computer, where they are displayed on a monitor for the health care provider to read.

You must lie still during the PET scan so that the machine can produce clear images of your lungs.

The test takes about 90 minutes.

You must sign a consent form before having this test. You will be told not to eat anything for 4 - 6 hours before the PET scan, although you will be able to drink water.

Tell your doctor if you are pregnant or think you might be pregnant.

Also tell your doctor about any prescription and over-the-counter medicines that you are taking, because they may interfere with the test.

Be sure to mention if you have any allergies, or if you've had any recent imaging studies using injected dye (contrast). Tell the PET center if you have diabetes and are taking insulin.

During the test, you may need to wear a hospital gown. Take off any jewelry, dentures, and other metal objects because they could affect the scan results.

You will feel a sharp prick when the needle with the radioactive substance is inserted into your vein. You shouldn't feel anything during the actual PET scan.

Your doctor may order this test:

• To diagnose lung cancer
• To see if lung cancer has spread to other areas of the body. This is called staging. Staging helps guide future treatment and follow-up and gives you some idea of what to expect in the future.
• To determine whether a growth in the lungs seen on a CT scan is cancerous or noncancerous.
• To determine how well you're responding to cancer treatment.

There are no problems detected in the size, shape, or function of the lungs. There are no areas in which the radiotracer has abnormally collected.

Abnormal results may be due to:

• Cancer that has spread
• Lung cancer
• Solitary pulmonary nodule

The amount of radiation used in a PET scan is low. It is about the same amount of radiation as in most CT scans. Also, the radiation doesn't last for very long in your body.

However, women who are pregnant or are breastfeeding should let their doctor know before having this test. Infants and fetuses are more sensitive to the effects of radiation because their organs are still growing.

It is possible, although very unlikely, to have an allergic reaction to the radioactive tracer. Some people have pain, redness, or swelling at the injection site.

It is possible to have false results on a PET scan. Blood sugar or insulin levels may affect the test results in people with diabetes.

Most PET scans are now performed along with a CT scan. This combination scan is called a PET/CT.

Other tests that may be done instead of a PET scan include a gallium scan, CT scan, or MRI scan.

Silvestri GA, Jett J. Bronchogenic carcinoma. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA. Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa:Saunders Elsevier; 2005:chap 44.

Gould MK, Fletcher J, Iannettoni MD, Lynch WR, Midthun DE, Naidich DP, Ost DE. Evaluation of patients with pulmonary nodules: When is it lung cancer? ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007;132:208S-130S.

Wahl RL. Imaging. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG, eds. Abeloff's Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier Churchill Livingston;2008:chap 21.

Kieninger AN, Welsh R, Bendick PJ, Zelenock G, Chmielewski GW. Positron-emission tomography as a prognostic tool for early-stage lung cancer. Am J Surgery. 2006;191:433-436.

Lung gallium scan is a type of nuclear scan that uses radioactive gallium (Ga) to identify swelling (inflammation) in the lungs.

Gallium 67 lung scan; Lung scan; Gallium scan - lung; Scan - lung

Gallium is injected into a vein. The scan will be taken 6 - 24 hours after the gallium is injected. (Test time depends on whether your condition is acute or chronic.)

During the test, you lie on a table that moves underneath a scanner called a gamma camera. The camera detects the rays the gallium releases. Images display on a computer screen.

During the scan, it is important that you keep still to get a clear image. The technician can help make you comfortable before the scan begins. The test will take about 30 - 60 minutes.

You must sign an informed consent form. Several hours to 1 day before the scan, you will get an injection of gallium at the hospital or doctor's office.

Just before the scan, remove jewelry, dentures, or other metal objects that can affect the scan. Take off the clothing on the upper half of your body and put on a hospital gown.

The injection of gallium will sting, and the puncture site may hurt for several hours or days when touched.

The scan is painless. However, you must stay still. This may cause discomfort for some patients. The wait between the injection and scan can cause some patients to become agitated.

This test is most often performed when there is evidence of inflammation in the lungs (sarcoidosis).

The lungs should appear of normal size and texture, and should take up very little gallium.

• Sarcoidosis
• Other respiratory infections

Other conditions under which the test may be performed:

• Primary pulmonary hypertension
• Pulmonary embolus
• Tumors

There is some risk to children or unborn babies. Because a pregnant or nursing woman may pass on radiation, special precautions will be made.

For women who are not pregnant or nursing and for men, there is very little risk from the radiation in gallium, because the amount is very small. There are increased risks if you are exposed to radiation (such as x-rays, and scans) many times. Discuss any concerns you have about radiation with the health care provider who recommends the test.

Usually the health care provider will recommend this scan based on the results of a chest x-ray. Small defects may not be visible on the scan.

Volcanic smog (vog) is created when sulfur dioxide and other gases released from a volcano react with oxygen, moisture, dust, and sunlight in the atmosphere.

Volcanic smog can irritate the lungs and worsen existing lung problems.

Vog

Volcanoes release plumes of ash, dust, sulfur dioxide, carbon monoxide, and other harmful gases into the air. These chemicals (the most harmful of which is sulfur dioxide) react with oxygen, moisture, and sunlight in the atmosphere to form a type of air pollution called volcanic smog (vog).

Volcanic smog contains a mixture of gases and highly acidic aerosols (tiny particles and droplets), mainly sulfuric acid and other sulfur-related compounds. These aerosols are small enough to be inhaled deep into the lungs.

When people breathe in vog, it irritates the lungs and mucus membranes, and it can affect lung function. Volcanic smog is also thought to interfere with the normal functioning of the immune system.

The acidic particles in vog can worsen the following lung conditions:

• Asthma
• Bronchitis
• Chronic obstructive pulmonary disease (COPD)
• Emphysema

Children and people with circulation problems are also more likely to feel the effects of volcanic smog.

Symptoms of volcanic smog exposure include:

• Breathing difficulties, shortness of breath
• Coughing
• Eye watering and irritation
• Flu-like symptoms
• Headaches
• Increased mucus production
• Lack of energy
• Sore throat

PREVENTIVE MEASURES

If you have breathing problems, take the following measures to prevent the respiratory effects of volcanic smog:

• Stay indoors as much as possible. People who have lung conditions should limit physical activity outdoors. Keep windows and doors closed and the air conditioning on. It can also help to use an air cleaner/purifier.
• When you do have to go outside, wear a paper or gauze surgical mask that covers your nose and mouth. Wetting the mask with a solution made from baking soda and water can further protect your lungs.
• Take your COPD or asthma medications as prescribed.
• Do not smoke. Smoking can further irritate your lungs.
• Drink a lot of fluids, especially warm fluids (such as tea).
• Try bending forward at the waist slightly to make it easier for you to breathe.
• Practice breathing exercises to keep your lungs as healthy as possible. Breathe in through your nose and out through your mouth while your lips are almost closed (pursed-lip breathing). Or, breathe deeply, expanding your belly without moving your chest (diaphragmatic breathing).

EMERGENCY SYMPTOMS

If your asthma or COPD symptoms suddenly get worse, try using your rescue inhaler. If your symptoms don't improve, call 911 or the emergency number immediately, or have someone take you to the emergency room.

Call your health care provider if you:

• Are coughing up more mucus than usual, or the mucus is changing color
• Are coughing up blood
• Are running a high fever (over 100° Fahrenheit)
• Have flu-like symptoms
• Have severe chest pain or tightness
• Have shortness of breath or wheezing that is getting worse
• Have swelling in your legs or abdomen

Feldman J, Tilling RI. Volcanic eruptions. In: Auerbach PS. Wilderness Medicine. 5th ed. Philadelphia, Pa:Mosby Elsevier;2007:chap 15.

Naumova EN. Emergency room visits for respiratory conditions in children increased after Guagua Pichincha volcanic eruptions in April 2000 in Quito, Ecuador observational study: time series analysis. Environ Health. 2007;6:21.

Volcanic Air Pollution -- A Hazard in Hawai'i. U.S. Geological Survey. Last updated October 2004. U.S. Geological Survey Fact Sheet 169-197.

Review Date: 06/22/2010

Allen J. Blaivas, DO, Clinical Assistant Professor of Medicine UMDNJ-NJMS, Attending Physician in the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Veteran Affairs, VA New Jersey Health Care System, East Orange, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.