Stage 4 (Very Severe) Emphysema

Medically Reviewed by Paul Boyce, MD on March 08, 2024
4 min read

Emphysema is a disease that makes it hard for you to catch your breath. Stage 4 means your emphysema is advanced and that your breathing is very severely affected.

At this stage, smoking or other pollutants have destroyed many of the 300 million tiny air sacs, or alveoli, that help bring oxygen into your body and get rid of carbon dioxide.

As the alveoli break down, your bronchial tubes start to collapse, too. That can trap air in your lungs and make your chest puff out, one of the telltale signs of advanced emphysema.

Emphysema is progressive, meaning that over time, it’ll get even harder for you to breathe, though some treatments may slow this process.

For emphysema, stages are a measure of how well you can breathe. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is one widely used formula. Stage 4 is the most severe of the four GOLD stages. Doctors use your stages and many other things to evaluate how serious your disease is.

A machine called a spirometer measures your breathing for the GOLD standards. It takes two key measurements:

Forced vital capacity (FVC): How much air you can breathe out after taking the biggest breath you can.

Forced expiratory volume-one second (FEV1): How much air you can breathe out in the first second after that big breath.

Your doctor uses those numbers to calculate how well you compare to your healthy peers.

You have emphysema if the ratio of FEV1 to FVC is less than 70%. That means that after you exhaled for 1 second, 30% or more of the air in your lungs hasn’t emptied out.

GOLD stage 4 emphysema is when the amount of air you can breathe out in 1 second is less than 30% of the average of a healthy person.

Stage 4 is also called very severe emphysema. It can be particularly hard if you’re 65 and older because breathing problems are more likely to interfere with basic daily tasks like dressing, cooking, or climbing stairs, and cause symptoms that send you to the hospital.

But breathing is not the only measure that doctors use to assess your condition.

Once your doctor diagnoses your emphysema and establishes your GOLD stage, they’ll look at other signs and symptoms to make a full assessment of your condition. They’ll want to know if you:

  • Have problems sleeping
  • Make high-pitched wheezing sounds when you breathe
  • Cough often, or cough up colored mucus
  • Have low blood oxygen levels
  • Have flare-ups when your breathing worsens
  • Have gone to the hospital for your emphysema symptoms
  • Get lung-related infections
  • Show signs of scarring, holes, or enlargement in your lungs on x-rays and other imaging scans


Emphysema is one of three conditions that fall under the umbrella of chronic obstructive pulmonary disease (COPD). The other two are:

You can’t reverse your emphysema or COPD. But you can ease your symptoms and slow the progress of the disease. And the earlier you act, the better.

Quit smoking. It’s the No. 1 cause of emphysema, and all COPD conditions. If you smoke, quitting is the single best step you can take.

Breathe smarter. You can learn to breathe with pulmonary rehabilitation therapy. You follow a set of breathing techniques and physical exercises to lessen breathlessness and boost your stamina. Your doctor or a specialized breathing therapist can help design a program for you.

Get to a healthy weight. In early emphysema, you may need to lose some pounds. But as your disease gets worse, you might find you need to put weight back on. Nutritional therapy from your doctor or a nutritionist can help you customize a diet based on your size, health, and activity level.

Emphysema is a condition that gets worse over time. But treatments can ease your symptoms or slow down your disease progress.

Bronchodilators: You inhale these medications to relax and to expand your airways. This allows more air into your lungs so your body gets more oxygen. Talk to your doctor about which type is right for you.

Oxygen: If your blood oxygen levels get low for too long, your doctor might suggest taking in extra oxygen from a machine through tubes that go into your nose. It’s most beneficial if you have very low blood oxygen levels, not just moderately low. You and your doctor will typically reassess your oxygen needs every 2 to 3 months.

Surgery: In serious cases, your doctor might suggest lung volume reduction surgery to remove a diseased part of your lung and stitch the rest back together. The purpose is to help improve the stretchiness of your lungs and take pressure off the muscles that help you breathe. This treatment is not right for everyone, but it has shown some promise in certain types of patients with emphysema.

Transplant: If other treatments haven’t helped you, your doctor might recommend surgery to take out one or both of your lungs and replace them with donated lungs. Transplants are for people who likely will die without one.