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Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign...

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Obstructive Obstructive Pulmonary Diseases Pulmonary Diseases
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Page 1: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Obstructive Obstructive Pulmonary DiseasesPulmonary Diseases

Page 2: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Obstructive Obstructive Pulmonary DiseasesPulmonary Diseases

1. Localised (Mechanical Obstruction) - Acute

• Tumor

• Trauma

• Foreign body

2. Diffuse - Distal airway disease (COPD) - Chronic

• Chronic bronchitis

• Bronchiectasis

• Emphysema

• Asthma

Page 3: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Chronic Obstructive Chronic Obstructive Pulmonary DiseasesPulmonary Diseases

Page 4: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

COPD is defined as a disease state characterized by the presence of airflow obstruction due to Chronic bronchitis

Bronchiectasis

Emphysema

Asthma

The airflow obstruction generally is progressive, may be accompanied by airway hyperreactivity, and may be partially reversible.

Page 5: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

The term “chronic obstructive pulmonary disease” (COPD) refers to a group of conditions; They are accompanied by chronic or recurrent

obstruction to air flow within the lung,

They share a major symptom: dyspnea.

Page 6: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pathophysiology Pathological changes in COPD occur in:

the large (central) airways,

the small (peripheral) bronchioles,

the lung parenchyma.

1. The increased number of activated polymorphonuclear leukocytes and macrophages release elastases lung destruction

2. Increased oxidative stress free radicals (released by phagocytes, and polymorphonuclear leukocytes) apoptosis or necrosis of exposed cells

Page 7: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Factors in COPD

Smoking

Air pollution and COPD

Other factors Airway hyperresponsiveness

Alpha1-antitrypsin (a 1-AT) deficiency

Page 8: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

SMOKING The primary cause of COPD is exposure to tobacco

smoke.

Chronic bronchitis is primarily a disease of cigarette smokers: 90% of cases occur in smokers.

Chronic bronchitis occurs in less than 5% of nonsmokers, 10% to 15% of moderate smokers, and more than 25% of heavy smokers.

Page 9: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Smoke

The primary cause of COPD Clinically significant COPD

• chronic bronchitis

• emphysema

Almost 4000 chemicals, 43 carcinogens

Neoplastic and Non-neoplastic diseases

Page 10: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Neoplastic diseases (cancers): Lung

Bladder

Stomach

Pancreas

Oral cavity

Larynx

Cervix

Non-neoplastic diseases: Lung diseases

Gastritis

Atherosclerosis

Ischemic heart disease

Hypertension

Bürger’s disease

Page 11: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pathophysiology of COPD in smokers

Smokers have greater numbers of neutrophils and macrophages in their alveoli

Smoking

• Stimulates release of elastase from neutrophils

• Enhances elastolytic protease(s) activity in macrophages

• Inhibition of antielastase activity– oxidants in cigarette smoke – oxygen free radicals secreted by neutrophils inhibit

1-AT.

Page 12: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

AIR POLLUTION

The use of solid fuels for cooking and heating may result in high levels of indoor air pollution and the development of COPD sulfur dioxide

nitrogen dioxide

Page 13: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

OTHER FACTORS IN COPD Airway hyperresponsiveness

Smokers with airway hyperresponsiveness are at increased risk of developing COPD with an accelerated decline in lung function

1-antitrypsin deficiency 1-antitrypsin deficiency is the only known genetic risk

factor for developing COPD (panacinar emphysema) and accounts for less than 1% of all cases

(1-antitrypsin is a protease inhibitor produced by the liver that acts predominantly by inhibiting neutrophil elastase in the lungs)

Page 14: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Chronic BronchitisChronic Bronchitis

BronchiectasisBronchiectasis

EmphysemaEmphysema

AsthmaAsthma

Page 15: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Chronic bronchitis is four to ten times more common in heavy smokers irrespective of age, sex, and occupation.

When persistent for years, it may

(1) lead to cor pulmonale and heart failure,

(2) cause atypical metaplasia and dysplasia of the respiratory epithelium (cancerous transformation).

Chronic BronchitisChronic Bronchitis

Page 16: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Productive cough

Acute & Chronic inflammation of mucosa

Secondary Pulmonary Infections (Haemophilus influenzae and Streptococcus pneumoniae)

Inflammation retention infection obstructioninflammation....... (circulus viciosus).

Acute respiratory failure in patients with advanced chronic bronchitis

Clinical observations: Chronic bronchitis

Page 17: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pathology: Chronic bronchitis

Mucous gland enlargement is the histologic hallmark of chronic bronchitis

Increased ratio of mucous cells to serous ones

Excess mucus in airways

Increase in the number of goblet cells (hyperplasia)

Lack of cilia

Thickening of the bronchial wall

Mucous gland enlargement and edema (which leads to encroachment on the bronchial lumen)

Increased smooth muscle (which may indicate bronchial hyperreactivity)

Squamous metaplasia of the bronchial epithelium (epithelial damage from tobacco smoke)

Page 18: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

HistologyHistology

Earliest features of chronic bronchitis are hypersecretion of mucus in the large airways,

hypertrophy of the submucosal glands in the trachea and bronchi.

As chronic bronchitis persists, marked increase in goblet cells of small airways (small

bronchi and bronchioles)

excessive mucus production that contributes to airway obstruction.

Page 19: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Chronic Bronchitis: HistologyHistology

Page 20: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

BronchiBronchiectasisectasis Bronchiectasis is a chronic necrotizing infection of

the bronchi and bronchioles leading to or associated with abnormal dilation of these airways.

It is manifested clinically by cough,

fever,

the expectoration of copious amounts of foul-smelling, purulent sputum.

To be considered bronchiectasis, the dilation should be permanent; reversible bronchial dilation often accompanies viral and

bacterial pneumonia

Page 21: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Etiology: Bronchial obstruction

Localized (to the obstructed lung segment): tumor

foreign bodies

mucous impaction

Diffuse (obstructive airway diseases): asthma

chronic bronchitis

Page 22: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pathogenesis

Smoking irritation of mucosa Mucus hypersecretion Obstruction, Cough

Atelectasis

Metaplasia loss of ciliated epithelium

Retention of secretion

Secondary infection

Recurrent Inflammation and Fibrosis

Destruction of bronchial wall

Dilated bronchus filled with pus

Page 23: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

The dilatation ("-ectasis") results from recurrent inflammations, and

contraction of scar surrounding the bronchus.

Page 24: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Gross Pathology

Generalized bronchiectasis is usually bilateral and is most common in the lower lobes

The left more commonly involved than the right

Bronchi are dilated and have white or yellow thickened walls

Bronchial lumens frequently contain thick, mucopurulent secretions

Page 25: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Gross Pathology

On gross examination, bronchial dilation is saccular, cylindrical or varicose (they may produce cystic pattern):

Saccular bronchiectasis: bronchi are severely dilated and end blindly in dilated sacs, with collapse and fibrosis of the distal lung parenchyma.

Cylindrical bronchiectasis shows uniform, moderate dilation. It is a milder disease than saccular bronchiectasis and leads to fewer

clinical symptoms.

Varicose bronchiectasis: bronchi resemble varicose veins when visualized by radiologic bronchography, with irregular dilations and constrictions. Bronchiolar obliteration is not as severe, and parenchymal

abnormalities are variable.

Page 26: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bronchiectasis

Page 27: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bronchiectasis

Page 28: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pleural adhesions

Page 29: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Microscopy

Severe inflammation of bronchi and bronchioles

Destruction of all components of the bronchial wall

Collapse of distal lung parenchyma, the damaged bronchi dilate

Hypersecretion of mucus

Abnormalities of the surface epithelium squamous metaplasia

increased goblet cells

Lymphoid follicles are often seen in the bronchial walls

Scarred and often obliterated bronchi and bronchioles (distal ones)

The bronchial arteries increase in size to supply the inflamed bronchial wall and fibrous tissue

Page 30: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

In the full-blown, active case:

Intense acute and chronic inflammatory exudation within the walls of the bronchi and bronchioles,

A vicious circle

pool of mucus is liable to further infection, which leads to progressive destruction of the bronchial walls more mucus new infection .......

Desquamation of the lining epithelium and extensive areas of ulceration (necrosis),

Pseudostratification of the columnar cells or squamous metaplasia of the remaining epithelium,

Necrosis (destroys the bronchial or bronchiolar walls and forms a lung abscess),

In chronic cases:

Fibrosis of the bronchial and bronchiolar walls.

Page 31: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bronchiectasis

intense acute and chronic inflammatory exudation

desquamation of the lining epithelium

Page 32: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bronchiectasis

Necrosis (destroys the bronchial or bronchiolar walls and forms a lung abscess).

Page 33: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Complications

amyloidosis

meningitis

brain abscesses

cor pulmonale

pneumonia

empyema

septicemia

Page 34: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

EmphysemaEmphysema Emphysema is a chronic lung disease characterized

by enlargement of airspaces distal to the terminal bronchioles, with destruction of their walls but without fibrosis.

Loss of elasticity of the lung with some destruction of the alveoli.

Emphysema is a condition of the lung characterized by abnormal permanent enlargement of the airspaces distal to

the terminal bronchiole, accompanied by destruction of their walls, and without

obvious fibrosis.

Emphysema causes obstruction to air flow.

Page 35: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Classification of Emphysema

(1) Centrilobular (centriacinar)

(2) Panacinar (panlobular)

(3) Localised (paraseptal)

(4) Senile Of these, the first two are the most important

clinically

Page 36: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

1.1. CCentrilobular emphysemaentrilobular emphysema Most frequent

Usually associated with cigarette smoking (often in association with chronic bronchitis)

Destruction of the cluster of terminal bronchioles near the end of the bronchiolar tree in the central part of the pulmonary lobule

Dilated respiratory bronchioles form enlarged airspaces that are separated from each other and from the lobular septa by normal alveolar ducts and alveoli

Distal structures also may be involved

Bronchioles proximal to the emphysematous spaces are inflamed and narrowed

Centrilobular emphysema is most severe in the upper zones of the lung, the upper lobe, and the superior segment of the lower lobe

Page 37: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

The walls of the emphysematous spaces often contain large amounts of black pigment.

Inflammation around bronchi and bronchioles and in the septa is common.

Focal dust emphysema, a disease of coal miners, resembles centrilobular emphysema but differs in that the enlarged spaces are smaller and more regular and inflammation of the bronchioles is not apparent.

Page 38: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Smokers lung Normal Lung

Page 39: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Smokers lung – Emphysema

Page 40: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Centrilobular Emphysema

Page 41: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Severe Centrilobular Emphysema

Page 42: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Microscopy

Page 43: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

22. . Panacinar Panacinar (Panlobular)(Panlobular) Emphysema Emphysema

The acinus is uniformly involved, with destruction of the alveolar septa from the center to the periphery of the acinus (entire alveolus distal to the terminal bronchiole)

In the final stage, panacinar emphysema leaves behind a lacy network of supporting tissue (cotton-candy lung)

This variant occurs in several situations

Page 44: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Diffuse panacinar emphysema is typically associated with a 1-AT deficiency [a congenital disease caused by a1-protease inhibitor ("antitrypsin") deficiency]

It is also often found in cigarette smokers in association with centrilobular emphysema In such cases, the panacinar pattern tends to

occur in the lower zones of the lung, whereas centrilobular emphysema is seen in the upper regions

Page 45: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Grossly, cut surface of the lung shows diffuse enlargement of airspaces in the affected parenchyma.

Often the enlarged spaces are traversed by delicate, spider-web-like strands representing the residual alveolar walls.

As in centrilobular emphysema, fibrosis is not seen.

Page 46: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Panacinar (Panlobular) Emphysema

Page 47: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

33. Localised . Localised ((Paraseptal)Paraseptal) Emphysema Emphysema

Characterized by destruction of alveoli and resulting emphysema in only one or at most a few locations

The remainder of the lungs is normal

The lesion is usually found at the apex of an upper lobe, although it may occur anywhere in the pulmonary parenchyma, such as in a subpleural location.

Progression of localized emphysema can result in a large area of destruction, termed a bulla, which ranges in size from as small as 2 cm to a large lesion (Bullous Emphysema).

Although it is of no clinical significance itself, rupture of an area of localized emphysema produces spontaneous pneumothorax (sudden death).

Page 48: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bullous Emphysema

Page 49: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Bullous Emphysema

Page 50: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

4. Senile emphysema4. Senile emphysema

This form of emphysema is usually associated with "old age“

It may occur anywhere in the pulmonary parenchyma

Page 51: Obstructive Pulmonary Diseases. 1. Localised (Mechanical Obstruction) - Acute Tumor Trauma Foreign body 2. Diffuse - Distal airway disease (COPD) - Chronic.

Pathophysiology

TOBACCO: The major cause of emphysema

Emphysema results when elastolytic activity increases or antielastolytic activity is reduced.

Increased numbers of neutrophils, which contain serine elastase and other proteases, are found in the bronchoalveolar lavage fluid of smokers.

Smoking also interferes with alpha1-antitrypsin (a1-AT) activity.

1-AT DEFICIENCY: A hereditary deficiency 1-AT: a circulating glycoprotein produced in the liver

Major inhibitor of a variety of proteases, including elastase, trypsin, chymotrypsin, thrombin, and bacterial proteases

Its most important action to inhibit neutrophil elastase, an enzyme that digests elastin and other structural components of the alveolar septa


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