1. Obstructive Pulmonary Disease

2. Characterized by airway obstruction that is increased with expiration.
More force is required to expire a given volume of air, or emptying of lungs is slowed, or both.
The most common obstructive diseases are asthma, chronic bronchitis, and emphysema.

3. COPD
Asthma
Emphysema
Chronic
Bronchitis

4. Many people have both chronic bronchitis and emphysema, and together these are often called chronic obstructive pulmonary disease - COPD
Major symptom of obstructive pulmonary disease is dyspnea, and wheezing.

5. COPD Asthma Emphysema Pathologic Diagnosis Chronic Bronchitis
Physiologic Diagnosis
Chronic
Bronchitis
Clinical Diagnosis

6. 1- Bronchial Asthma More intermittent and acute than COPD.
It is a reversible disorder
It occurs at all ages.
Runs in families, so evidence genetics plays a role.
Environmental factors interact with inherited factors to increase the risk of asthma.

7. Childhood exposure to high levels of allergens, smoking and/or respiratory viruses increases chances of developing asthma.
Major events in acute asthma attack are
bronchiolar constriction,
mucus hyper-secretion
inflammatory swelling.

8. Pathogenesis
Smooth muscle spasm in bronchioles.
Vascular congestion.
Edema formation.
Production of thick mucus.
Impaired muco-ciliary function.
Thickening of airway walls.

9. Untreated, this can lead to airway damage that is irreversible.
Obstruction increases resistance to air flow and decreases flow rates
Impaired expiration causes hyperinflation of alveoli, and increases the work of breathing

10. Clinical manifestations
Dyspnea
Sometimes, cough
Wheezing
Attacks may continue from few hours to days or even weeks.
During remission individual is asymptomatic and pulmonary function tests are normal

11. 2- Chronic Bronchitis
Hyper-secretion of mucus and chronic productive cough for at least 3 months of the year for at least two consecutive years.
Incidence may be increased up to 20 times in persons who smoke and more in persons exposed to air pollution.

13. Pathophysiology
Inspired irritants result in inflammatory cell infiltration into the bronchial wall.
Causes bronchial edema and increases size and number of mucus glands and goblet cells.
Mucus is thick, and can’t be cleared because of impaired ciliary function.
Increases susceptibility to infection and injury

14. Initially affects only larger bronchi, but eventually all airways involved.
Airways collapse in early expiration, blocked by mucus leads to hypo-ventilation
Hypoxemia
Air trapping prevents respiratory muscles from functioning efficiently (barrel chest).

15. Barrel Chest

17. Treatment Best treatment is PREVENTION.
Stop smoking halts progression of the disease
Bronchodilators, expectorants, and chest physical therapy.
Acute attacks may require antibiotics, and steroids.
Oxygen therapy may be required

18. 3- Emphysema
Abnormal, permanent enlargement of the gas-exchange airways and destruction of the alveolar walls.
Obstruction results from changes in lung tissue rather than mucus production and inflammation (pathological changes).
Major mechanism is loss of elastic recoil

19. Major cause is smoking
Other causes are air pollution and recurrent respiratory infections
Primary emphysema linked to an inherited deficiency of the enzyme alpha 1- antitrypsin which can affect lung tissue.

20. Normal Lung versus Emphysema

21. Normal Lung versus Emphysema

22. Pathophysiology
Begins with the destruction of the alveolar septa, which eliminates portions of the capillary bed, and increases the volume of air in the alveolus.
Continued alveolar loss and loss of elastic recoil
Expiration becomes difficult, causing hyperexpansion of the chest
These are not effective in gas exchange and result in hypoxia.

23. Clinical manifestations
Dyspnea at rest
Barrel chest
Minimal wheezing
Prolonged expiration
Hypoventilation and hypoxia

24. Pursed Lip Breathing

25. Atelectasis
Collapse or incomplete expansion of part or all of the lung
Types:
Resorption (obstruction of airway).
Compressive (pleural effusion or pneumothorax)

27. Bronchiectasis
Dilatation of bronchi and bronchioles secondary to chronic inflammation
Associated conditions
Obstruction
Cystic fibrosis
Immotile cilia syndromes
Necrotizing pneumonia

29. Respiratory Failure 29

30. Respiratory Failure (RF)
The inability of the lungs to adequately oxygenate the blood and to clear it of carbon dioxide. RF could be :-
Acute RF:
Acute Respiratory Distress Syndrome (ARDS)
Pulmonary embolism
Direct injury to the lungs, airways or chest wall
Indirect due to injury of another body system, as brain. 30

31. Chronic respiratory failure
Due to progressive hypoventilation from airway obstruction or restrictive disease 31

32. Respiratory failure always presents with:-
Dysnpea always present, but may be difficult to detect a change in a chronic patient
Since nervous tissue is highly oxygen-dependent ---
Drowsiness, Memory and visual impairment,
Headache due to increased intracranial pressure due to cerebral vasodilatation

33. Two principal patterns:
1- Hypoxic Respiratory Failure
2- Hypoxic-Hypercapnic Respiratory Failure

34. 1- Hypoxic Respiratory Failure:
Seen when pO2 {oxygen partial pressure} falls to or below 60 mm Hg
Typically seen in:-
chronic bronchitis and emphysema.
lung consolidation due to bacterial infection (pneumonia).
in lung collapse,
pulmonary hypertension,
pulmonary embolism and ARDS. 34

35. With a progressive lowering of pO2, more widespread tissue damage and loss of consciousness can occur.

36. 2- Hypoxic-Hypercapnic Respiratory Failure
When arterial pCO2 {Carbon dioxide partial pressure} (normally 40 mm Hg) exceeds 45 mm HG, condition is called hypercapnia 36

37. Most often caused by airway obstructive conditions, and hypoventilation from CNS problem, thoracic cage or neuromuscular abnormalities.

38. CNS effects produce muscular tremors, drowsiness and coma.
Attempts to compensate include increased heart rate and vasodilatation, which produces warm, moist skin.
CNS effects produce muscular tremors, drowsiness and coma.
Hypercapnia also produces acidosis. 38

39. ARDS Mortality in persons < 60 is 40%
Those over 65 and immunocompromised still have mortality over 60 %
Most survivors have almost normal lung function 1 year after acute illness. 39

40. Clinical manifestations:
Symptoms developed progressively:
Hyperventilation → respiratory alkalosis → dyspnea and hypoxemia → metabolic acidosis → respiratory acidosis → further hypoxemia → hypotension, decreased cardiac output, death 40

41. Evaluation and Treatment
Diagnosis based on physical examination, blood gases and imaging
Treatment is based on early detection, supportive therapy and prevention of complications, esp. infection
Often requires mechanical ventilation. 41

42. Tumors of the Lung

43. Carcinoma of the Lung Causes 7% of all deaths
More common in males than females
Causes
85-95% smoking
1% asbestos + smoking (estimate)
Rare arsenic, chromium, nickel, 43

44. 44

45. Classification of Lung Carcinoma (Major Types)
Squamous cell carcinoma 35%
Adenocarcinoma 30%
Small cell carcinoma 25%
Large cell carcinoma 10% 45

46. Squamous cell carcinoma
Frequency: 35%
Smoking: X 25 (increased risk)
Males > females
Survival (5 years): %
Arises in bronchial squamous metaplasia
Centrally located
May cavitate 46

47. Squamous cell carcinoma

48. Adenocarcinoma Frequency: 30% Smoking: X 3 (increased risk)
Males < females
Survival (5 years): %
Peripheral

49. Bronchiolo-alveolar carcinoma
Frequency: 2 %
Smoking
Males = females
Survival (5 years): %.
Single or multiple tumor nodules

50. Small cell carcinoma Frequency: 25 % Smoking: 95% of patients
Males >> females
Survival (5 years): %.

51. Small cell carcinoma

52. Large Cell Carcinoma Frequency: 10 % Gross picture: Peripheral lesion
Microscopic
Wastebasket group of tumors that do not fit the criteria of a squamous cell carcinoma, adenocarcinoma, or small cell carcinoma
Prognosis: Similar to adenocarcinoma

53. Large Cell Carcinoma

54. Mesothelioma
Malignant tumor of mesothelial cells
Highly malignant neoplasm with short survival
Most patients (70%) have an asbestos exposure history
Asbestos exposure also increases the risk of pulmonary cancer
Smoking is not related to mesothelioma