Rheumatoid Arthritis In The Lungs

'Rheumatoid Arthritis Is More Than A Joint Disease'

The lungs may seem an unusual area to be attacked by Rheumatoid Arthritis – after all RA is a disease known to attack joints.

However, lung disease is the 2nd most common cause of death from Rheumatoid Arthritis so here we review everything you need to know about Rheumatoid Arthritis in the lungs.

Rheumatoid Arthritis In The Lungs – What Is It?

As discussed in previous articles, rheumatoid arthritis is an auto-immune disease whereby your bodies’ own protective white blood cells turn against you and start attacking your body – typically focusing on the synovial fluid around your joints. This leads to inflammation, pain and ultimately many problems with your joints.

The reality however is that rheumatoid arthritis is a disease that can affect almost any organ in your body. Lung disease (or interstitial lung disease) is the second largest reason for death from rheumatoid arthritis – second only to heart disease (ERAS Group, Young et al) 

Indeed, in some of the most recent studies, lung disease was the only organ issue found to have actively increased in frequency despite advance in the overall treatment of rheumatoid arthritis.

So while modern medicines and particularly alternative therapies have given many rheumatoid arthritis sufferers a new lease of life, an increasing number are are now finding their activities curtailed by trouble breathing.

According to the Arthritis Foundation, the figure for people developing lung disease from rheumatoid arthritis is as high as 10%.

Given how prevalent rheumatoid arthritis is around the world, that is a lot of sufferers.

Rheumatoid Arthritis in the lungs (sometimes referred to as ‘rheumatoid disease’) can present itself in one of four key ways –

1) Scarring or Interstitial Lung Disease.

Long-term inflammation and your bodies’ constant attack on the inflammation, will ultimately lead to scarring. The lungs are one of the areas that this scarring can present. When this scarring occurs around the alveoli (small air sacs that transfer oxygen into the bloodstream) then vital lung tissue is likely to be destroyed.

This is known as Interstitial lung disease and is both the most common and most deadly of the respiratory problems that can occur with rheumatoid arthritis.

The actual destruction of lung tissue is often also referred to as ‘pulmonary fibrosis’ and is likely to present with a cough and breathlessness as your bodies’ oxygen levels fall.

Unfortunately, it is not always easy to diagnose interstitial lung disease as the damage to your lungs may already be done by the time any obvious symptoms present themselves – especially if you are not already diagnosed with rheumatoid arthritis and therefore looking out for any subtle changes.

There are certain factors however that are known to greatly increase your chances of Interstitial Lung Disease –

  1. a) Smoking. Smokers are significantly more likely to develop ILD if they have rheumatoid arthritis, not least because of the damage on the lungs inflicted by smoking.
  2. b) Being Male. Men are statistically 2.5 times more likely to develop Interstitial Lung Disease from RA.
  3. c) Being aged 50-60 years of age. Statistically this is the most likely age that you develop lung complications if you have rheumatoid arthritis.
  4. d) Having Rheumatoid Arthritis for a long time. High levels of ‘Rheumatoid Factor’ increase the likelihood of developing ILD.
  5. e) Treatment with DMARDs. A number of drugs used to treat other symptoms of rheumatoid arthritis such as methotrexate have been known to damage the lungs. Thankfully, the chances are less than 1%, so the overall benefit is seen as well worth any risk.

Many more people with rheumatoid arthritis will have or will develop Interstitial lung disease than will actually realise it. Indeed, up to a quarter of all rheumatoid arthritis sufferers will have some impact on their lungs – but less than half of that 25% will see any progression to dangerous levels.

2) Lung Nodules.

We covered what rheumatoid nodules are and how they are formed in our article (‘What Is A Rheumatoid Nodule?’). They can also form in the lungs without necessarily showing any obvious symptoms.

In theory they are harmless enough – not being linked in any way to an increased chance of developing lung cancer.

However, don’t be fooled – even relatively futile nodules when they are in an organ as essential and delicate as your lungs can rupture, causing your lung to collapse.

3) Small Airway Obstruction

The constant inflammation causes infection and together this causes the walls of your lungs to thicken in response to the constant cycle of injury (bronchiolitis).

The result is a build-up of protective mucus similar to that seen with COPD (chronic obstructive pulmonary disease) which causes chronic cough, tired/ weakness and shortness of breath.

4) Pleural Disease

The layer of tissue that surrounds the lungs is known as the Pleura (Ploor-uh). When your body develops rheumatoid arthritis in the lungs, this tissue can quickly become inflamed.

When it becomes inflamed, there is often a gathering of fluid between different layers of the pleura. This is termed ‘Pleural Effusion’ and may cause a lot of pain when breathing as well as shortness of breath.

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Symptoms Of Rheumatoid Arthritis In the Lungs

Symptoms of rheumatoid arthritis in the lungs vary a little, depending on the variation and severity, but broadly speaking these will include –

  • Painful Breathing
  • Shortness of breath
  • Dry Cough
  • Weakness
  • Unintentional Weight Loss
  • Fatigue
  • Decreased Appetite
  • Chronic fevers

“When Should I See A Doctor?”

The simple answer is as soon as you experience any of the above symptoms, especially if you already have rheumatoid arthritis. With any from of arthritis, and especially rheumatoid arthritis time is key.

Don’t be afraid to waste your doctors time – if you experience pain breathing or any difficulty whatsoever, it is always best to get it checked out. It might just save your life.

Diagnosis

Below is a typical process that you will go through if you have not already been diagnosed with rheumatoid arthritis. If you already have the diagnosis, it is likely they will jump straight to x-rays…

Clinical Examination

Your doctor will ask you a range of quetions about your symptoms andif there is any family history of RA. They may also measure pulse and heart rate, before referring you on to the hospital for tests.

Blood Tests

These may be requested in the early days to check for evidence of inflammation including C-reactive proteins.

X-Rays 

These will look for signs of fluid or darker scarring on the lungs. You may also be able to see the presence of rheumatoid nodules as well.

Biopsy

A biopsy removes a small piece of lung tissue to check for evidence of scarring and inflammation. Tissue samples could be taken either surgically or via a bronchoscopy (a scope with a tiny camera that is inserted through your nose or mouth and cuts a tiny amount of tissue for investigation)

A surgical biopsy involves a doctor pushing a small needle through your chest and removing a small sample for examination.

Lung Function Tests

(also known as Pulmonary Function Tests). This involves a series of tests to ascertain how much air you can blow out of your lungs (lung capacity) as well the level of gas in their lungs.

A prime example is a Peak Flow Meter, where you forcibly exhale the entire contents of your lungs by breathing out as hard as possible in to measuring tube. This type of test will show if your lung capacity is compromised in any way.

High Resolution CT Scan

(if other tests show anything). This produces high resolution cross-sectional images of your lung. Scarring is then easy to spot and provides a simple confirmation of rheumatoid arthritis in the lungs.

Treatments for Rheumatoid Arthritis In the Lungs

Treatment for rheumatoid arthritis in the lungs varies according to type of damage that has been done. It is important to emphasize that, like all treatments for rheumatoid arthritis, there is no cure.

The focus then is around maintaining a good quality of life and stopping the disease from progressing. We’ll look individually at how each variant of lung disease can be treated –

Scarring or Interstitial Lung Disease.

This is by far the most common (and most deadly). There are four basic treatment options available for treating scarring of the lung tissue.

1) Medication.

There is some debate as to how successful these are nowadays and a recent study in 2015 has suggested that medications that try to act as an immunosuppressant for rheumatoid arthritis in the lungs actually have very little effect for the risk involved.

2) Pulmonary Rehabilitation.

This involves a mix of education and exercise. The education is around methods of managing being short of breath and the exercises are designed to slowly increase their lung capacity, although these are less popular as rheumatoid arthritis sufferers often have joint pain as well that stops them from exercising.

3) Oxygen Therapy.

A face mask leading to an oxygen tank can supply special air that contains more oxygen than normal. This can be either a temporary measure like using an asthma inhaler or permanent oxygen supplied via a nasal cannula.

4) Lung Transplant.

If your interstitial lung disease has reached a very advanced stage. The process of waiting for a suitable lung however can be a very long process and with rheumatoid arthritis, there is no guarantee that you’ll be approved in the first place.

Small Lung Nodules.

Unless the nodules are actively believed to be exacerbating your symptoms, it is unlikely any treatment at all will be given. They are generally harmless and trying to forcibly treat them is likely to cause much more harm than good.

Pleural Disease (Effusion).

Pleural disease is basically a gathering of fluid between layers of lung tissue. If this is the cause of your lung disease, then a consultant can surgically drain the fluid away. It is likely to build up again but it can also be drained again in future to give you the best quality of life.

Small Airway Obstruction.

Increased mucus production may be treated with a whole range of drugs, most recently a group of mucolytics have been developed that specifically thin the mucus produced so that it can be coughed up and cleared. The other option is a bronchodilator or asthma medication to open up the airways again.

Pneumonia

Pneumonia is not rheumatoid arthritis, but the chances of getting pneumonia if you have RA in the lungs are roughly doubled. Obviously, steps such as having an annual flu jab and at least one specific pneumonia injection can help to reduce the risk somewhat.

However, whether it be down to the activity of the inflammation leading to infection or the use of oral steroids that weaken your immune system, the fact is that even with precautions, there is still a very significantly higher chance of getting pneumonia if you have rheumatoid arthritis.

Make sure you have all your preventative jabs to reduce the chances of contracting pneumonia.

The Final Word –

Rheumatoid arthritis in the lungs may not be the first issue you think of when being diagnosed, but actually of all the areas it can spread to, only the heart is more likely to have a fatal outcome.

Indeed, a review of 10 separate studies by Assayag et al put the median survival rate at 3.2 years to 8.1 years for people with interstitial lung disease as a result of rheumatoid arthritis.

The difficulty with rheumatoid in the lungs is that it not always possible to stop the disease from progressing there from other areas. All you can really do is learn to reduce the risk by giving up smoking, and getting early treatment.

As with all forms of rheumatoid arthritis, the sooner you get it diagnosed and treated, the easier it is to prevent further progression. Time in all cases of RA really is key.

Frequently Asked Questions

That’s a good question – it’s true of heart disease from RA and Eye problems too. Millions of articles on joint issues, but very little on the most prevalent killers.

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References –

1.A. Young, G. Koduri, M. Batley, E. Kulinskaya, A. Gough, S. Norton, J. Dixey on behalf of the Early Rheumatoid Arthritis Study (ERAS) group (April 2007). Mortality in rheumatoid arthritis. Increased in the early course of disease, in ischaemic heart disease and in pulmonary fibrosis. Rheumatology, Volume 46, Issue 2
2. The Arthritis Foundation. RA and Lung Disease: What You Need to Know.
3. Kundan Iqbal, Clive Kelly. (December 2015). Treatment of rheumatoid arthritis-associated interstitial lung disease: a perspective review. Therapeutic Advances In Musculoskeletal Disease

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