1. Middle Examination Multiple choice 50% Short answers 25%
Long answers %
Case analysis %
The weekend of 10th week, 150 min
总论+心血管系统疾病

2. Chapter 9 Diseases of the Respiratory System
Department Of Pathology
Guangxi Medical University
Zili Lv 吕自力

3. Anatomic Structures and Functions
Good afternoon everybody, today we will talk about some diseases happened in respiratory system. Ok, first, please let me introduce myself. My name is lvzili, my english name is lilian, I wish you can enjoy my teaching. And if you have any question, please do not hesitate to put up your hand and ask me, ok?
Ok, let’s begin. First we go over the anatomic structures about respiratory system. Do you remember what is the respiratory composed of?
The respiratory system is divided into three principal divisions:
Conducting portion: nasal cavity, nasopharynx, larynx, trachea, bronchi and bronchioles.
Transitional portion: including respiratory bronchioles.
Respiratory portion: consists of the alveoli and their associated structures.
Histological structure of the trachea:
Pseudostratified columnar, ciliated epithelium
Goblet cells
Sero-mucous glands
Cartilage rings
Nose, sinuses, nasopharynx, larynx,
Trachea, bronchi, bronchiloe, terminal bronchiloe,
Warm, filter, humidify the air
Speech, air exchange
Alveolar pneumocyte
Speudostratified clolumnar

4. Bronchi
Bronchioles
Alveolar ducts
Alveoli

5. It is chest x-ray picture, the white part is the heart, and the dark is lung, it is clear.

6. Clinical features of respiratory diseases
1. Cough
2. Sputum Production咳痰
3. Hemoptysis 咯血
4. Dyspnoea呼吸困难
5. Cyanosis紫绀
6. Chest pain
cough: the most common symptoms. caused by entrying of foreign material into the larynx; accumultion of secretion in the lower respiratory tract. Two types: dry cough—without any sputum
Sputum production: examination of sputum is useful, can find the reason: tumour or infection
Hemoptysis: blood in the sputum. Reasons: left heart failure---lung congestion; lung infarction;lung tumor
Dyspena: difficult to breath. Obstruction of the tract, pain
Cyanosis: the color of the skin and mucous membranes have been changed ,
Chest pain: means the parietal pleura is involoved

7. Contents (6 hrs) 1. Pulmonary infections
2. Chronic obstructive pulmonary diseases & chronic cor pulmonale
3. Chronic diffuse interstitial lung disease, carcinoma of nasopharynx and lung.

8. Pulmonary infections
Acute Pneumonia
Chronic Pneumonia

9. Classification of pneumonia
Clinical circumstance
Primary and Secondary
Etiological agent
Bacterial, Virus, Fungal
Host reaction
Fibrinous & Suppurative
Anatomical pattern
Lobar & Lobular
Acute pneumonia is an acute inflammation of the lung parenchyma resulting from infection of alveoli and respiratory bronchioles.
When it occur in a healthy individual----primary
The patient is seriously ill, the infection is secondary,

10. Case 1 analysis
History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

11. T: 40℃, R: 32 times/min.
Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.
Blood examination: WBC: 13.5x 109/ L

12. BACTERIUM PNEUMONIA Lobar pneumonia Lobular pneumonia Legionella pneumonia

13. Lobar pneumonia Affects a large part, or the entirety of a lobe
Relatively uncommon in infancy and old age
Affects males more than females
90% due to pneumococcus (肺炎球菌）
Cough and fever with purulent or Rusty Sputum铁锈色痰

14. A. Etiology Pathogen: Streptococcus pneumonia 肺炎球菌 III型
Infective Route:
Inhalation, Aspiration 吸入
Risk Factors：
Cold, drunk, tired, diabetes
Inhalation: the bacterium comes from atmosphere
Aspiration: the bacterium stay in the nose sinus

15. B. Pathology* Acute exudative fibrinous inflammation （急性纤维素性炎）
Involves one whole lobe or several lobes
The bronchi are not involved

16. Acute congestion 充血水肿期 Red hepatization 红色肝样变期
Pathologic Features
Acute congestion 充血水肿期
Red hepatization 红色肝样变期
Gray hepatization 灰色肝样变期
Resolution 溶解消散期

17. 1. Stage of acute congestion 1st-2nd day
(1)Gross changes:
Heavy, dark red and firm
(2)Microscopic change
Fluid, RBC, WBC in the air space
(3)Clinical features:
Acute congestion is the early stage of infection: the bacteria are replicate in the alveolar space, and spread to the others, the normal alveolar defense have been overcome, the capillaries will be invloved

18. Stage of acute congestion
Active dilation of alveolar capiilaries
The normal space is filled with air, but the in the lobar pneumonia, is filled with fluid
Alveolar capillaries: Dilated
Air space: Fluid, RBC, WBC

19. Stage of acute congestion Clinical Features
Fever, cough, cyanopathy (发绀)
Chest pain
Bacteremia
Bacteria can be found in sputum

20. （1）Grossly 2. Stage of Red Hepatization: 2nd-4th day
Red and consolidation, just like liver
（1）Grossly

21. (2)Microscopic changes of red hepatization
A. Capillaries congestion
B. Exudation:
Fibrin, large number of RBC
C. Fibrinous pleurisy

22. Microscopical changes
Alveolar congestion is still present
The alveolar space is filled with red blood cells, neutriphils, fibrin

23. 红色肝样变期X线特点 (3) Chest x-ray
The middle segment of right upper lobe become consolidated and show large-area uniform dense shadow.
红色肝样变期X线特点

24. (4) Clinical features of red hepatization
Fever, cough, chest pain
Rapid breathing, cyanopathy
Dullness浊音
Vocal fremitus enhancement 语颤增强
Rusty sputum 铁锈色痰
The infection is controlled at this stage, either naturally or by antibiotic therapy, which eliminate the bacterium
Rusty sputum: the RBC is phagocytosed by macrophage, the RBC will be dissoved---hemosiderin laden macrophages

25. 3. Stage of gray hepatization: 5th-6th day (1)Gross changes of grey hepatization
Dry
Gray
Firm
Consolidation

26. (2)Histological changes
Capillary is not dilated anymore.
Alveolar space is filled with neutrophil and fibrin

27. Histological changes of grey hepatization
The features of consolidation are still present.
But the infection has been controlled and there is neither hyperemia nor continued exudation and neutrophil emigration
The fibrinous exudates persist within the alveoli.

28. X-ray features of gray hepatization
(3)Chest x-ray: high dense shadow can be found at the right upper lobe
X-ray features of gray hepatization

29. (4)Clinical features of gray hepatization
Consolidation: dullness, vocal fremitus enhancement
Sputum: mucus purulent sputum
Dyspnoea(缺氧）: is not obvious

30. 4. Stage of Resolution, 7 days later
Gross changes: Friable and mottled
Microscope: The fibrin and cell debris are digested by enzymatic, The exudation is remove.

31. Chest X-ray

32. Pathologic Features (4 stages)
Acute congestion
Red hepatization
Grey hepatization
Resolution

33. LOBULAR PNEMONIA 小叶性肺炎 (Bronchopneumonia) (支气管肺炎)

34. The lobule includes 3-5 terminal bronchioles and their distant structure.
Includes: respiratory bronchioles,alveolar duct, alveolar sacs and alveolus

35. Lobular pneumonia Bronchopneumonia
Bronchi are infected
Patchy consolidation
Centred on inflamed bronchioles or bronchi
Secondary pneumonia
Less virulent agents, in infancy or old age
Suppurative inflammation化脓性炎

36. A. Etiology Pathogen: many bacteria,
Infection via: Inhalation, Aspiration
Risk Factors: Secondary
In patients who develop secondary pneumonias of a bronchopneumonia pattern---many bacteria,such as staphylococcus aureus, gram-negative bacilli

37. B. Pathology Gross: Lower lobes, dorsal side
Multiple firm areas, around inflamed bronchioles.
Lobular pneumonia is characterized by foci of acute suppurative inflammation centered on bronchioles.
The consolidation may be patchy through one lobe but is more frequently multilobar and frequently bilateral and basal
The lesions are gray-red to yellow, and up to 0.5 to 1 cm in diameter.
Confluence of these foci producing confluent bronchopneumonia.

38. Dry, granular, gray-red to yellow, and poorly delimited at the their margins
They vary in size up to 0.5 to 1 cm in diameter.
Confluences of these foci occurs in the more florid instances

39. Microscope: 1. Multiple lesions
Purulent bronchitis and bronchiolitis (化脓性细支气管炎)
2. Alveolar spaces surrounding the lesions are filled with neutrophil
3. Compensatory emphysema (代偿性肺气肿)

40. Suppurative exudate fills the brochi and adjacent alveolar spaces
Neutrophils are dominat in this exdation.

41. C. Clinical Features The onset is insidious, nonspecific
Low-grade fever
Dyspnea is not prominent
The typical feature is
Purulent Sputum脓痰*

42. Chest x-ray
Several scattered patchy shadows evidently in bilateral lower lobes

43. Legionella pneumonia, 军团菌肺炎
嗜肺军团杆菌
急性纤维素性化脓性炎—典型病例,严重者坏死—脓肿
临床表现复杂:肺内\外表现

44. Legionella pneumonia, 军团菌肺炎
                                                      
急性纤维素性化脓性炎
acute fibrino-purulent exudative pneumonia

45. 军团菌病(legionaires disease)是由革兰染色阴性的嗜肺军团杆菌(legionella pneumophila)引起的一种以肺炎为主的全身性疾病，1976年被确认。

46. Resolution
Lobar pneumonia
Air space pneumonia
Lobular pneumonia
Complications

47. Complications of acute air space pneumonia
Pleura involvement
Bacteremia
Suppuration (Abscess Formation)
Necrotizing bacterial pneumonia
Pulmonay carnification肺肉质变
Pleura involvement: the pleura is involved, the inflammation spread to the pleura
Bacteremia: is the most serious complication of pneumococcal penumonia.---death, meningitis and endocarditis
Suppuration: liquefactive necrosis of alveoli leading to areas of destryoed lung replaced by pus
Necrotizing bacterial pneumonia: rare complication, extremly severe necrosis of the lung associated with rapidly progressive disease with a high mortality rate.
Pulmonary carnification: the exudation is taken place by granulation tissue
It may convert part of lungs into solid tissue.

48. Lung abscess

49. Pulmonary carnification

50. What are the differences?
Distribution
Number
Host
reaction
Clinical
Features

51. Acute interstitial pneumonia间质性肺炎
1. Agents: Virus (SARS, Avian influenza, Swine Flu) and Mycoplasma or Pneumocystis
2. Interstitium
3. Atypical pneumonia
4. Infiltration with lymphocyte, monocyte
Acute interstitial pneumonia results from infection by agents that are predominantly obligate intracellular pathogens.
Infection with these pathogens evokes an acute inflammation that is usually restricted to the interstitum wihtout involvement of the alveolar spaces.

52. Pathologic Features of Viral pneumonia
The alveolar septa are expanded
Cell infiltrate: lymphocyte, plasma cells
Air spaces are air filled
Epithelial necrosis
Inclusion bodies 病毒包涵体
Multinucleated giant cells 多核巨细胞
Hyaline membranes 透明膜
The septa is expanded by hyperemia, edema, and a cellular infiltrate composed of lymphocytes and plasma cells
Inclusion bodies: cytomegalovirus

54. Viral Pneumonia Hayline membrane Expanded septum
Necrosis of epithelial
Inclusion bodies

55. SARS Severe Acute Respiratory Syndrom (SARS) 重症急性呼吸综合征
Atypical pneumonia（非典型肺炎）
Cornonavirus 变异的冠状病毒
Extensive consolidation, hyaline membrane, necrosis, pulmonary fibrosis
Die in respiratory distress
Cornonavirus, a new member of the family coronviridae

56. In the end of 2002 to 2003, SARS came to be epidemic all over the world, especially in Asia, in China, over 5000 people suffered from this disease, more than 50% died in this disease. many people had to wear the respirator , kitten too, the murderer was the virus, coronarovirus.

57. Clinical features
Fever, usually greater than 38, chills, cough ,dyspnea, difficult in breath, headache, diarrhea,
Flu-like

58. Hyaline membrane
Necrosis of epithilum
Diffuse alveolar damage in varying phases of organization
Multinucleated giant cells

59. Electro microscope
Under electro microscope, we can see in the plasma of the cell, replication of the virus

61. Avian Influenza 禽流感 H5N1 Interstitial Atypical 人畜共患传染病
Avian influenza is called as bird flu
Infectious disease of birds caused by strains of the influenza virus
人畜共患传染病

62. Bird flu An infection disease of birds 1997, Hong Kong, outbreak
Vascular disturbances
Fever, cough
All the other organs can be affected, for example, liver, heart and kidney.
This is a bird disease caused by infection of strains of the influenza virus,
The first cases of avian influenza viruses in humans happened in 1997, Hong Kong, it killed more than 140 million birds and 60 people.

64. H1N1, Swine influenza A

65. H1N1, Swine influenza A 临床表现 轻症：同普通流感；重症：肺炎，坏死性脑病 合并症：急性呼吸窘迫综合征
病理：肺部表现为支气管壁坏死、中性粒细胞浸润、弥漫性肺泡损害伴肺透明膜病变。
发病机制：病毒损伤肺泡微血管导致肺出血与血栓形成，体内免疫因子可对抗病毒感染并修复损伤，但炎症反应过度、渗出液充满肺组织又使肺瘢痕形成，进而限制肺功能。

66. H1N1 and H5N1

67. Mycoplasma pneumonia 支原体肺炎
Interstitial pneumonia
Atypical pneumonia
Congested, edematous, mononuclear cells infiltration
The patient is an adolescent or a young adult
Respiratory symptoms may be minimal or severe,
Pathcy ,segmental in distribution

68. Lobar pneumonia
Air space
pneumonia
Lobular pneumonia
Viral pneumonia
Interstitial
pneumonia
Mycoplasma pneumonia

69. ARDS Acute Respiratory Distress Syndrome
An acute diffuse alveolar injury
Terminal events in many of the patients
Serious ill, the mortality rate > 50%
Results from ischemic, endotoxins, enzymes.

71. Case 1 analysis
History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

72. T: 40℃, R: 32 times/min.
Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.
Blood examination:
WBC: 13.5x 109/ L

73. Questions What is the diagnosis? Which type of inflammation?
Why does the patient cough with the “rusty” sputum?

74. WHY? Half a year later, this student was enrolled to the army.
The chest x-ray indicated there was a nodule in his left lung.
The nodule was checked under microscope, there was much granulation tissue in the alveolar spaces.
WHY?

75. Case abstract 2
Male, 70-year-old, he had suffered hypertensive heart disease and left heart failure for half a year, and cough and expectoration for 1 year. These symptoms aggravated 4 days ago with fever and purulent sputum.

76. T: 38℃, HR: 112 times/min, R: 35 times/min, BP: 22.6/13.5 kPa.
Blood WBC: 10.2 X 109/L
X-ray: Several scattered patchy shadows evidently in bilateral lower lobes.

77. Questions What is the diagnosis? Which type of inflammation?
Why do patients cough with the purulent sputum?

78. Summary
How to differentiate the lobar pneumonia and the bronchopneumonia?
What is the “rusty sputum”?

79. See you next time!
2017/4/16 79