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Chronic Obstructive Pulmonary Diseases

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1 Chronic Obstructive Pulmonary Diseases
Chronic Bronchitis Emphysema Bronchiectasis Bronchial Asthma Small Air way disease Bronchiolitis

2 Pathogenesis Prolonged exposure to cigarette smoke and/or other air pollutants. Airway obstruction at times may result in a check-valve mechanism leading to overdistension and rupture of alveolar septa, especially if the latter are inflamed and exposed to high positive pressure (i.e. barotrauma). With loss of alveolar surface in emphysema, there is a decrease in surface tension, resulting in expiratory airway collapse. Additional investigative work continues in an effort to link disease states to pathogenesis

3 Etiology By far the most common etiological cause of COPD remains smoking. Even after the client quits smoking, the disease process continues to worsen. Air pollution and occupation also play an important role in COPD. Smog and second-hand smoke contribute to worsening of the disease.

4 Cont. Occupational exposure to irritating fumes and dusts may aggravate COPD. Silicosis and other pneumonoconioses may bring about lung fibrosis and focal emphysema. Exposure to certain vegetable dusts, such as cotton fiber, molds and fungi in grain dust, may increase airway resistance and sometimes produce permanent respiratory impairment.

5 Cont. Exposures to irritating gases, produce pulmonary edema, bronchiolitis and at times permanent parenchymal damage. Chlorine Oxides of nitrogen and sulfur, Repeated bronchopulmonary infections can also intensify the existing pathological changes, playing a role in destruction of lung parenchyma and the progression of COPD.

6 Chronic Bronchitis Definition: Chronic bronchitis is a clinical syndrome defined by chronic sputum production Persistent cough with sputum production for at least 3 months in at least 2 consecutive years Anatomic site Bronchus

7 Morphology Hyperemia and edema of mm of lungs
Mucinous secretions or casts filling in the air ways Increase in the size and numbers of mucous secreting glands Bronchial or bronciolar mucous plugging, fibrosis, inflammation and fibrosis Squamous metaplaisa or dysplasia of bronchial epithelium

8 Chronic Bronchitis Pathophysiology
Cilia Damaged Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Cilia are destroyed

9 Chronic Bronchitis Pathophysiology
Narrowing of airway Starting w/ bronchi  smaller airways airflow resistance work of breathing Hypoventilation & CO2 retention  hypoxemia & hypercapnea

10 Chronic Bronchitis Pathophysiology
Bronchospasm often occurs End result Hypoxemia Hypercapnea Polycythemia (increase RBCs) Cyanosis Cor pulmonale (enlargement of right side of heart

11 Cartilage damage in long standing cases
Degenerative changes, atrophy and loss of bronchial cartilage were common features of most chronic bronchitic specimens This usually being related to intrinsic changes in the chondrocyte phenotype, including proliferative and matrix-degrading properties. Mast cells and macrophages were often observed in close association with the bronchial cartilage, suggesting that inflammatory cells may also contribute to the mechanisms of bronchial cartilage degradation and loss

12 Inflammatory Cells Studies show that smokers with symptoms of chronic bronchitis have an increased number of inflammatory cells in their bronchial glands when compared with asymptomatic smokers. This inflammatory process consists predominantly of neutrophils and macrophages, and of an increased proportion of CD8+ T-lymphocytes Mast cells

13 Mast cells Lymphocytes Neutrophils Macrophages
Macrophages, Mast cells, Lymphocytes and Neutrophils

14 Neutrophils Lymphocytes Mast cells Macrophages

15 This inflammatory process consists predominantly of neutrophils and macrophages, and of an increased proportion of CD8+ T-lymphocytes and Mast Cells                                                              

16 Pathogenesis Chronic irritation of airways
Smoking Dust Air pollutants etc The major risk factor for the development of chronic bronchitis is cigarette smoking Infective agents Secondary factor These irritants cause Hypersecretions of mucous Subsequent hypertrophy of mucous glands Metaplasia inflammation

17 Emphysema Pulmonary emphysema is described in clinical, radiological and physiologic terms, but the condition is best defined morphologically Definition:Abnormal enlargement of airspaces distal to the terminal bronchioles with destruction of their wall It is characterized by destruction and enlargement of alveoli

18 Cont. Although the normal lung has about 35,000 terminal bronchioles and their total internal cross-sectional area is at least 40 times as great as that of the lobar bronchi but the bronchioles are more delicate and vulnerable.

19 Cont Bronchioles may be obstructed partially or completely, temporarily or permanently, by thickening of their walls, by collapse due to loss of elasticity of the surrounding parenchyma, or by influx of exudates.

20 Cont In advanced emphysema, the lungs are large, pale, and relatively bloodless. They do not readily collapse. They many contain many superficial blebs or bullae, which occasionally are huge. The right ventricle of the heart is often enlarged (cor pulmonale), reflecting pulmonary arterial hypertension.

21 Emphysema: Pathophysiology
Structural changes Hyperinflation of alveoli Destruction of alveolar & alveolar-capillary walls Small airways narrow Lung elasticity decreases

22 Emphysema Loss of Lung Surface Area for Gas Exchange and Oxygen Transport Loss of Lung Surface area is due to death of Lung Endothelial Cells Polycyclic aromatic hydrocarbons (PAHs) in Cigarette Smoke and in Environmental Pollution may cause endothelial cell death

23 Emphysema: Pathophysiology
Mechanisms of structural change Obstruction of small bronchioles Proteolytic enzymes destroy alveolar tissue Elastin & collagen are destroyed Support structure is destroyed “paper bag” lungs

24 Emphysema: Pathophysiology
The end result: Alveoli lose elastic recoil, then distend, & eventually blow out. Small airways collapse or narrow Air trapping Hyperinflation Decreased surface area for ventilation

25 Emphysema: Clinical Manifestations
Early stages Dyspnea Non productive cough Diaphragm flattens A-P diameter increases “Barrel chest” Hypoxemia may occur Increased respiratory rate Respiratory alkalosis Prolonged expiratory phase Tripod position

26 Emphysema: Clinical Manifestations
Later stages Hypercapnea Purse-lip breathing Muscle retraction Use of accessory muscles to breathe Underweight No appetite & increase breathing workload Loss of subcutaneous fat Lung sounds diminished

27 Clinical Manifestations
Pulmonary function  residual volume,  lung capacity, DECREASED FEV1, vital capacity maybe normal Arterial blood gases Normal in moderate disease May develop respiratory alkalosis Later: hypercapnia and respiratory acidosis Chest x-ray Flattened diaphragm hyperinflation

28 Classification Anatomical Distribution Cetriacinar Panacinar
Paraseptal Irregular

29 Pathogenesis Protease anti Protease Theory Pollutants in environment
Hereditary deficiency of the major protease inhibitors Laurell and Eriksson –1963 – deficiency of α1-antitrypsin and emphysema Pollutants in environment smoking of cigarettes exhalations from cars, dust from grain Recruitment of neutrophils stimulation of macrophages and epithelial cells to produce TNF- α, IL-8 and LTB4 Elastase release from leukocytes and tissue macrophages Inactivation of α1-antitrypsin by oxidants in tobacco smoke or free radicals released from the neutrophils


31 Diseases in which misfolding of a given protein results in improper trafficking

32 Diseases in which misfolding of a given protein results in improper trafficking
polymers of alpha1 antitrypsin molecules will form. These will be retained in the liver (where alpha1 antitrypsin is produced) and will not reach the lungs

33 increased lung lucency
hyper aeration increased lung lucency decreased vessel size Flattening of the Diaphragm Increased Lung Height Decreased Peripheral Vascular Markings

34 Chest X-Ray Changes in Emphysema:
The two primary findings are: Increased Lung Volumes, i.e., hyperaeration or overinflation. Lung Destruction (bullae or decreased vascularity which gives increased lung lucency and decreased vessel size ). In end-stage disease, emphysema and chronic obstructive pulmonary disease can result in pulmonary arterial hypertension and eventually cor pulmonale (cp) - which causes an increase in the pulmonary arterial size, as well as right ventricular enlargement and cardiomegaly.

35 Normal acinus


37 Morphology Centrilobular Emphysema Panlobular Emphysema

38 Peripheral alveolar damage
Paraseptal Peripheral alveolar damage


40 Other types of Emphysema
1 Bullous Emphysema (also known as Bullous Lung Disease): Bullous emphysema is so named when there are multiple large bullae associated with a compromise in pulmonary function. It is usually associated with concomitant emphysema, although occasionally, it can be familial

41 Bullous Emphysema   Subpleural Type: These subpleural bullae contain only gas with no alveolar remnants or blood vessels. They are often located in the apex of the upper lung zone, and along the costophrenic rim of the middle lobe and lingua, but may be seen in the vicinity of parenchymal scars. Superficial Type: These bullae are found along the anterior edge of the upper and/or middle lung zones, or lingula, and over the diaphragms. They contains blood vessels and strands of partially-destroyed lung. Deep Type: These bullae are found within the lung substance and contain strands of partially-destroyed lung tissue and blood vessels.

42 2.Giant Bullous Emphysema: ("Vanishing Lung Syndrome" or "Primary Bullous Disease of the Lungs")
It is usually associated with young males who show large progressive upper lung zone bullae that are often asymmetric. The giant bullous lesions occupy greater than or equal to one-third of the hemithorax.

43 Cont. 3.Focal Dust Emphysema ( This is focal emphysema surrounding silicotic nodules. 4.Congenital Lobar Emphysema (CLE) 5.Interstitial Emphysema

44 Bronchiectasis Bronchiectasis is a chronic lung disease that is characterized by permanent dilatation of the bronchi and fibrosis of the lung. It is defined as the pathological, irreversible dilation of bronchi , due to destruction of the bronchilal walls and their supporting tissues It is highly associated with chronic bacterial infection Often looked at, as the final common pathway of many injurious processes


46 Cont. Bronchiectasis , although uncommon,bears the potential to cause severe illness , including repeated respiratory infections , disabling cough, purulent sputum, shortness of breath, chest pain and occasionally hemoptysis, with significant impact on the health and the quality of life of the affected person

47 Types of Bronchiectasis
Bronchiectasis means irreversible dilation and distortion of the bronchi and bronchioles. Pathologically, bronchiectasis can be divided into four types




51 Cylindrical Bronchiectasis
The first type, cylindrical bronchiectasis, is characterized by uniform dilatation of bronchi, that extends into the lung periphery, without tapering. Tubular bronchiectasis is simply the absence of normal bronchial tapering and is usually a manifestation of severe chronic bronchitis rather than of true bronchial wall destruction

52 Bronciectasis Cylindrical Forma

53 Varicose Bronchiectasis
The second type is called varicose bronchiectasis and is characterized by irregular and beaded outline of bronchi, with alternating areas of constriction and dilatation.

54 Saccular Bronchiectasis.
The third type is called cystic or saccular bronchiectasis and is the most severe form of the disease. The bronchi dilate, forming large cysts, which are usually filled with air and fluid. Saccular bronchiectasis is the classic advanced form characterized by irregular dilatations and narrowing. The term cystic is used when the dilatations are especially large and numerous

55 Bronchiectasis Saccular Form

56 Follicular Bronchiectasis
The fourth type of bronchiectasis is called follicular and is characterized by extensive lymphoid nodules within the bronchial walls. It usually occurs following childhood infections

57 Cont. Repeated or prolonged episodes of pneumonitis,
Inhaled foreign objects or Neoplasms have been known to cause bronchiectasis. When the bronchiectatic process involves most or all of the bronchial tree, whether in one or both lungs, it is believed to be genetic or developmental in origin

58 ASTHMA Definition Asthma is a chronic inflammatory disorder of airways. Many cells and mediators are involved in this process – eosinophils, mast cells and T-lymphocytes.

59 Asthma Reversible inflammation & obstruction Intermittent attacks
Sudden onset Varies from person to person Severity can vary from shortness of breath to death

60 Bronchial Hypersensitivity
Chronic inflammation is connected with bronchial hyperreactivity and leads to episodes of wheezing, coughing, tightness in the chest, breathlessness, shortage of breath specially at night and in the morning. This episodes are usually connected with variable obstruction which is reversible spontaneously or by treatment.

61 Types A) Allergic asthma B) Non-allergic asthma
asthma induced by immunological mechanisms. IgE induced asthma IgE antibodies triggers early and late-phase of response, T- lymphocytes late and opožděné responses. B) Non-allergic asthma asthma induced by non-immunological triggers Intermittent and persistent

62 Response of Inflammation
Inflammation causes obstruction of airways by: Acute bronchoconstriction Swelling of bronchial wall Chronic production of mucous Remodeling of airways walls

63 Risk factors: Individual predisposition Environment
genetic variability – 5. a 11. chromosome atopy, bronchial hyperreactivity, male or female, nation Environment exposition to allergens professional chemicals which lead to sensitivity, viral and bacterial infection, food, smoking, social and economic society, number of family members, psychosomatic influence

64 Asthma: Pathophysiology
Swelling of mucus membranes (edema) Spasm of smooth muscle in bronchioles Increased airway resistance Increased mucus gland secretion

65 Asthma: Pathophysiology
Early phase response: 30 – 60 minutes Allergen or irritant activates mast cells Inflammatory mediators are released histamine, bradykinin, leukotrienes, prostaglandins, platelet-activating- factor, chemotactic factors, cytokines Intense inflammation occurs Bronchial smooth muscle constricts Increased vasodilation and permeability Epithelial damage Bronchospasm Increased mucus secretion Edema

66 Late phase response: 5 – 6 hours
Characterized by inflammation Eosinophils and neutrophils infiltrate Mediators are released mast cells release histamine and additional mediators Self-perpetuating cycle Lymphocytes and monocytes invade as well Future attacks may be worse because of increased airway reactivity that results from late phase response Individual becomes hyperresponsive to specific allergens and non-specific irritants such as cold air and dust Specific triggers can be difficult to identify and less stimulation is required to produce a reaction

67 Cells involved in chronic allergic inflammation
1. Eosinophils 2. Mast cells 3. T-lymphocytes 4. Neutrophils 5. Basophils

68 T-lymphocytes Eosinophils Basophils Macrophage NEUTROPHIL Mast cell

69 Pathogenesis Acute inflammation Remodeling of airways
Chronic inflammation Symptoms of bronchoconstriction Exacerbation nonspecific hyperreactivity Ongoing obstruction of airway

70 Remodeling destruction of brush epithelium in airways swelling of the bronchial wall stimulation of proliferation of fibroblasts deposition of collagen in lamina reticularis of basal membrane hypertrophy of smooth muscles hyperplasia of goblet cells

71 The process of remodeling is involved by:
Th2 lymphocytes (CD25+, production of IL-4,13,5,6,10) antigen presenting cells mast cells (tryptase-converting angiotensin I to angiotensin II, hypertrophy of smooth muscles, histamin – fibrogenetic effect) eosinophils (long-living in epithelium and submucoses, create lipids –PAF, LTC4,LTD4, LTB4, peptides, cytokines, TGF-α, TGF-β, IL-1,3, GM-CSF, ECP) alveolar macrophages (production of TNF-α, IL-6) epithelial cells (desquamation of epithelium, lost of integrity, TGF-β, IGF-1, KGF- β, alteration of differentiation and proliferation of epithelial cells, apoptosis) endothelial cells

72 Cont. myocytes (proliferation of myocytes - after stimulation with IL-
11, which is produced by mezenchymal cells after stimulation with allergen, PGDF, EGF, the effect of gelatinase A (MMP-2) and B (MMP-9), production of IL-6,8, eotaxin, PGE2, RANTES, MCP-1,2,3, expression of ICAM-1, VCAM-1, production of NO, GM-CSF, IL-5) fibroblasts (activation of fibroblasts, creation of myofibroblasts, release of GM-CSF and TGF-β, increasing proinflammatory activity of eosinophils)

73 Subepithelial structures:
thickness of basal membrane increasing deposition of extracellular matrix under epithelium deposition of collagen I., III., IV., V. and VII. in reticular membrane increasing deposition of proteoglycans (lumican, biblycan, decorin, fibromodulin, hyaluron, versica) tenascin (corresponds with activity of chronic inflammation) fibronectin

74 Decrease of elasticity of the wall Inflammation
Increasing number of mucous glands Increasing number of smooth muscles fibres Sever bronchospasms during exacerbation Increase of mucous secretion during Release of fibrogenetic factors Ongoing of inflammatory cells Elastolysis Deposition of collagen in basal and Epithelial membranes Decrease of elasticity of the wall Inflammation

75 Cytokines involved in pathogenesis of asthma
IL-4 - cross-linking of immunoglobulines in B lymphocytes – production of IgE and IgG4 - increases of expression of VCAM-1 and mucous secretion - inhibits of activation of Th1 and production of IFNγ IL-13 - induces production of IgE a IgG4 - activates mast cells - increases bronchial hyperreactivity and contractility of smooth muscles, affects the differentiation of cilia - induces the production of eotaxin, VCAM-1 - suppress production of pro-inflammatory cytokines

76 Cont. IL-5 - produced by mast cells and Th2 lymphocytes, epithelial cells and eosinophils - affects the proliferation and the differentiation of B lymphocytes - induces expression of IL-2R - proliferating and differentiating factor for eosinophils IL-12 - produced by macrophages, dendritic cells and monocytes - decreases production of Th2 cytokines and then production of IgE and IgG1 - decreases number of eosinophils in peripheral blood and in sputum

77 Cont. IL-10 - large immunosupressive and anti-inflammatory effect
- decreases expression of iNOS, COX2 decreases release of IL-2, expression of MHC class II., CD80, CD86 and CD32 on the surface of APC and then presentation of allergen, RANTES, IL-5 - correlation with asthma severity

78 Cont. - IFNγ - low levels in atopic people
- stimulatory effects on Th1 cells, inhibitory effects on Th2 cells - the nebulissation of IFNγ decreases the number of eosinophils in BAL but this effect is not significant TGF-β - remodeling - induction of expression of Fas receptor on the surface of epithelial cells, activation of apoptosis, phagocytosis by macrophages, exudation of plasma,fibrosis

79 Etiological Classification of asthma:
A. Atopic (allergic) asthma - in combination with allergic rhinitis, atopic dermatitis, genetic predisposition - confirmation of spec. IgE antibodies, prick tests, inhalation challenge B. Endogenous asthma - without specific known influence, obviously in women after exposition to cold weather, refract to the standard therapy C. Exercise induced asthma - physical exercising, provocation by inhalation of chemicals, cold or hot weather

80 Cont. D. Aspirin induced asthma
- typical triads-nasal polyps, urticaria and asthma induced by application of aspirin - other drugs E. Allergic bronchopulmonary aspergillosis - aspergillus acts as an allergen challenge in atopic people and induces aspergillus asthma or alergic bronchopulmonary aspergillosis - in the chest radiography are intermitent infiltrates in lungs, the viscosity of mucous is increased and mucous plugs, bronchiectasia

81 Cont. F. Gastroesophageal reflux - bronchospasm induced by reflex
G. Sinobronchial syndrome - combination of sinusitis with nasal polyps and with asthma H. Professional asthma - induced by inhalation and exposition to industry chemicals CH. Asthmatic equivalent - dry cough, irritating, without breathlessness

82 Classification of grading of asthma
Grade 1. Intermitent asthma - rare symptoms < than 1x per week, short episodes of worsening - night symptoms 2x monthly - no symptoms between attacks - PEF or FEV1 > 80%, variability < 20% Grade 2. Mild persistent asthma - symptoms <1x per day >1x per week - night symptoms > 2x per month - exacerbation can affect daily activity or sleeping - PEF or FEV1 > 80%, variability 20-30%

83 Cont. Grade 3. Moderate persistent asthma - Everyday symptoms
- Exacerbation affects daily activity and sleeping - Night symptoms > 1x per week - Everyday use of releasing drugs - PEF or FEV1 between %, variability > 30% Grade 4. Severe persistent asthma - Continuous symptoms - Frequent exacerbation - Physical activity is decreased - Frequent night symptoms - PEF or FEV1 < 60%, variability > 30%

84 Asthma: Early Clinical Manifestations
Expiratory & inspiratory wheezing Dry or moist non-productive cough Chest tightness Dyspnea Anxious &Agitated Prolonged expiratory phase Increased respiratory & heart rate Decreased PEFR

85 Asthma: Early Clinical Manifestations
Wheezing Chest tightness Dyspnea Cough Prolonged expiratory phase [1:3 or 1:4]

86 Asthma: Severe Clinical Manifestations
Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathing Use of accessory muscles Diaphoresis & pallor Cyanotic nail beds Flaring nostrils


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