2. DISEASES OF RESPIRATORY SYSTEM The Department of Pathology Zili Lv 吕自力 15907817634E-mail:lvzili@yahoo.com.cn

3. Go over Pneumonia Air space pneumonia Interstitial pneumonia lobar pneumonia lobular pneumonia viral pneumonia mycoplasma pneumonia

4. Respiratory system diseases 2 Chronic (diffuse) obstructive passage disease 慢性阻塞性肺病 Chronic cor pulmonale 慢性肺心病

5. Chronic Obstructive Pulmonary Diseases, COPD Chronic bronchitis 慢性支气管炎 Pulmonary emphysema 肺气肿 Bronchial asthma 支气管哮喘 Bronchiectasis 支气管扩张症

6. Section 1: Chronic Bronchitis p194 Definition: A persistent productive cough, sputum for at least 3 months in at least 2 consecutive years. The most common disease in respiratory system. More common in old age (<40 ) Most cases caused by smoking

7. A. Etiology and Pathogenesis Causes: 1.Cigarette smoking: 90% 2.Air pollution: sulfur dioxide and nitrogen dioxide, may contribute. 3. Microorganism infection is often present but plays a secondary role.

8. Etiology and Pathogenesis Smoking Pollution Infection Destroy the defensive mechanisms Hypertrophy of mucous glands Metaplasia of squamous Infiltration of inflammatory cells

9. B. Pathology The inflammation of trachea and larger bronchi Grossly: Hyperemia, Edema, Mucous or mucopurulent secretion

10. Histology The injury and regeneration of epithelia. The hypertrophy, hyperplasia and metaplasia of mucus- secreting glands. (Reid I >0.5) Infiltration with chronic and acute inflammatory cells.

11. Chronic bronchitis

12. Squamous metaplasia

13. An increase of goblet cells

15. C. Clinical Features Cough Sputum Puff Secretion

16. D. Complications Bronchiectasis Bronchopneumonia Cor pulmonale Chronic bronchitis Pulmonary emphysema

17. Section 2 Pulmonary Emphysema 肺气肿 p194 Emphysema : permanent enlargement of the airspaces distal to the terminal bronchioles. Accompanied by destruction of their walls.

19. A. Classification of emphysema Alveolar Interstitial: The air comes into the septa of the lung. Centriacinar Periacinar Panacinar Others type

21. Centriacinar 腺泡中央型 Heavy smokers

22. Panacinar 全腺泡型 A1-AT deficiency

23. Periacinar 腺泡周围型

24. B. Pathology Grossly: pale and voluminous lungs Normal lungs emphysema

26. Bullous lung Balloon-like >10 mm in diameter are prone to rupture causing spontaneous pneumothorax 自发 性气胸

27. Histology 1.Thinning and destruction of alveolar walls, septa broken, adjacent alveoli become confluent. 2. Terminal and respiratory bronchioles may be deformed. 3. The number of alveolar capillaries decreases.

28. Thinning and destruction of alveolar walls, large airspaces

29. C. Pathogenesis ProteasesAnti-proteases Leukocytes Smoking, Inflammation Alfa1-antitrypsin Inheritance

30. D. Clinical Features Cough : dry or productive Dyspnea Mucoid sputum Type A: Pink puffers Type B: Blue bloaters

31. Barrel chest

32. Relationship between chronic bronchitis and emphysema chronic bronchitis and emphysema usually co-exist because the major pathogenic mechanism, cigarette smoking, is common to both.

33. (3)Bronchial Asthma 支气管哮喘 P197 Increased responsiveness of tracheobronchial tree to a variety of stimuli. Bronchiolar smooth muscle contraction (bronchospasm 支气管痉挛 ). Paroxysmal attacks 阵发性 Mucus plugs in bronchi

34. A. Etiology and pathogenesis Hypersensitivity Inflammation Hyper-reactive airways Nerve system Bronchial smooth muscle spasm Hypersecretion—mucus plugs Increased vascular permeability

35. B. Clinical Features — episodic attacks Dyspnea Wheezing Dry cough

36. 4. BRONCHIECTASIS 支气管扩张症 Permanent dilation of bronchi and bronchioles Results from bronchial obstruction with distal infection and scarring Destruction of alveolar walls, especially interstitial elastin, and fibrosis of lung parenchyma

37. Chronic inflammation The destruction of the wall Dilation Congenital, hereditary Obstruction Fibrosis

38. Pathology, Gross 1) Lower lobes of bilateral lungs are more common, particularly left side 2) The airways may be dilated to as much as four times their usual diameter 3) The dilated bronchioles can be seen almost to the pleura.

40. Morphology Histological Destruction of the bronchial or bronchiolar walls Acute and chronic inflammatory exudate within the walls of the bronchi and bronchioles Ulceration formation: the desquamation of lining epithelium cause extensive areas of ulceration. Fibrosis of the bronchial and bronchiolar walls (in chronic cases). Lung abscess.

43. Clinical Features Cough Mucopurulent sputum Hemoptysis Finger-clubbing Dyspnoea Clubbing

44. Normal Clubbing

45. Complications Pneumonia, lung abscess Emphysema Remote abscesses Pulmonary hypertension Chronic cor pulmonale

46. Chronic cor pulmonale 慢性肺源性心脏病 A heart disease results from chronic lung diseases, chest or pulmonary vascular diseases. Pulmonary hypertension( 肺动脉高压 ). Thickened right ventricle( 右心室肥厚 ).

47. A. Etiology and pathogenesis 1)Recurrent pulmonary emboli 2)Heart disease: 3)Chronic obstructive or interstitial lung disease:

48. Chronic obstuctive pulmonary disease Abnormalities of the pulmonary vasculature Pulmonary arteriolar constriction Disorders affecting chest movement Pulmonary vascular bed Pulmonary hypertension Right ventricle hypertrophy Key

49. B. Pathology Lung Existed lung diseases: Medium-sized muscular arteries: proliferation of myo-intimal cells and smooth muscle cells, causing thickening of the intima and media with narrowing of the lumina Smaller arteries and arterioles: thickening, medial hypertrophy, and reduplication of the internal and external elastic membranes.

52. B. Pathology Heart Right ventricle hypertrophy: More than 1 cm in thickness (normal 0.3- 0.4cm) More than 500—700 gm The right ventricle and atrium may be dilated when failure occurs

54. Clinical features Cyanosis: hypoxemia Pulmonary encephalopathy Right-sided congestive heart failure--- congestion, edema of lower extremities, palpitation, ascites

55. SUMMARY COPD: Chronic bronchitis Asthma Pulmonary emphysema Bronchiectasis Pulmonary hypertension Chronic cor pulmonale

56. 65, woman, cough with purulent sputum after catching cold 15 years ago. She developed cough and expectoration of white spumy sputum every winter and spring. Since 3 years ago, she felt breath shortness and palpitation after physical labor.

57. Pitting edema occurred repeatedly on her lower limbs for 2 years. Two months ago after catching cold, she developed fever, cough with purulent sputum, palpitation, breath shortness, and abdominal distension, and could not lie down.

58. Physical examination: T: 37.6 ℃, HR:102 times/min, R: 30 times/min. Chronic sickness appearance, up- straight sit breathing, sleepiness, dark purple lip and skin, cervix venous engorgement

59. Chest: Barrel-shape chest, hyper- resonance to percussion, scattered dry and moist rales. Abdomen: Abdominal bulge, a large amount of ascites, the liver is hard with the rim under the rib 7.8 cm, lower limbs show pitting edema.

60. Questions 1. what is the pathological diagnosis of the patient? 2. how to explain the process of the development of the diseases about the patient.

61. Pathological diagnosis Chronic bronchitis Emphysema Chronic cor pulmonale complicated with: (1) right heart failure---- liver congestion, lower limbs edema, ascites (2) pulmonary encephalopathy

62. The relationship Chronic bronchitis---- emphysema---- chronic cor pulmonale---- right heart failure and pulmonary encephalopathy.