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Definition: A disease state characterised by airflow limitation that is not fully reversible

The airflow limitation is usually both progressive & associated with an abnormal inflammatory response of the lungs to noxious particles or gases

Disease of the lower respiratory tract

Term to bring together variety of clinical syndromes associated with airflow obstruction & destruction of the lung parenchyma

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Emphysema: abnormal, permanent enlargement of air spaces distal to terminal bronchiole, accompanied by destruction of walls without obvious fibrosis

Enlargement of distal air spaces (aka emphysema) is secondary result of small airway inflammation and destruction.

Different types are defined by site of damage.

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• Centri-acinar emphysema→

Centri-acinar emphysema

The central or proximal parts of the acini, formed by respiratory bronchioles, are affected, while distal alveoli are spared.

Both emphysematous and normal air spaces exist within the same acinus and lobule.

The lesions are more common and severe in the upper lobes, particularly in the apical segments.

In severe centriacinar emphysema the distal acinus also becomes involved,

and thus, the differentiation of cigarette smoking in people who do not have congenital deficiency of α1-antitrypsin.

• Pan-acinar emphysema

everything is affected, especially lower part. Acini are uniformly enlarged, from the level of the respiratory bronchiole to the terminal blind alveoli

It is the type of emphysema that occurs in α1-antitrypsin deficiency.

• Distal acinar emphysema

The proximal portion of the acinus is normal but the distal part is primarily involved.

Pneumothorax. Lung can rupture. Asymptomatic.

The emphysema is more striking adjacent to the pleura, along the lobular connective tissue septa, and at the margins

• Irregular emphysema

The acinus is irregularly involved, is almost invariably associated with scarring, such as that resulting from healed inflammatory diseases.

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defined by the presence of a persistent productive cough for at least 3 consecutive

months in at least 2 consecutive years.

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increased mucus, all irritants and chemicals will be stuck.

Less air can go through obstruction in bronchioles due to air trapping

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Inflammatory response. Chronic and acute cells.

CD8+ infiltrating.

Not only the lumen, but also the wall has response.

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Developed countries: 90% of people who have COPD are smokers.

Cigarette smoking is the most important underlying risk factor.

Chronic bronchitis is common among cigarette smoker and urban dwellers in smog-ridden cities.

Some studies indicate that 20% to 25% of men in the 40 to 65-year-old age group have the disease.

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Emphysema (chronic obstructive pulmonary disease) - centriacinar, panacinar, paraseptal

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Left image: increased goblet cells produnig mucosa = purple dots

pink = mucus?

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- Air pollution

-  Occupational exposures

-  Biomes heating fuels

-  Socioeconomic status

Cooking in poorly ventilated areas

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Patients with airflow obstruction related to COPD have a chronically reduced ratio of FEV₁/FVC.

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Smoking = most common cause

age

Alpha1-antitrypsin deficiency→proteinase inhibitor produced in liver. Seen in young COPD patients

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Increased RV, TLC / Air trapping→In COPD, there is often “air trapping” (increased residual volume and increased ratio of residual volume to total lung capacity) and progressive hyperinflation (increased total lung capacity) in more advanced disease.

Hyperinflation of the lungs→ Hyperinflation of the thorax during tidal breathing preserves (maintain) maximum expiratory airflow, because as lung volume increases, elastic recoil pressure increases, and airways enlarge so that airway resistance decreases.

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BAL and biopsies (smoker airways): increased numbers of neutrophil granulocytes

can release elastases and proteases —> may help cause emphysema

imbalance between protease and antiprotease activity causes the damage.

α1-Antitrypsin = major serum antiprotease, can be inactivated by cigarette smoke

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promote use of antibiotics and routine vaccines against flu, COVID, and pneumococci

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All these above leads to destroyed lung

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Excessive mucus secretion→beginning in the large airways

--> airway obstruction

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shorter cilia, cleaning system is not working, excessive production of mucus.

CD8+ cell present to clean the imflammation.

Simple blood test shows evidence, biopsy not necessary.

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Chronic bronchitis (COPD) - causes, symptoms, diagnosis, treatment & pathology

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→ Productive cough with white or clear sputum

→ Wheeze

→ Breathlessness

→ Colds symptoms in chest

→ Symptoms can be worsened by cold, foggy weather and atmospheric pollution

→ Hypertension

→ Osteoporosis

→ Depression

→ Weight loss

→ Reduced muscle mass

→ General weakness

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productive cough

wheezing

breathlessness

hypertension

weight change

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enlargement of fingers or toes

proliferation of connective tissues

can he hereditary, with specific cause

associated with other disorders e.g.) cyanotic heart disease, COPD

Mainly due to hypoxia, lung conditions

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Multiple symptoms needed to diagnose

Lung function test: assess airflow limitation

Chest rays: used at any stage

Arterial blood gases

look for acidosis

Look for Right ventricle hypertrophy: Cor pulmonale

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Check for most recent GOLD classification

AB&E

See lecture

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Variations of emphysema

compensentatory emphysema,

mediastinal emphysema

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stop Smoking

Drug therapy: used both for short term managementt of exacerbations and for long term relief of symptoms.

Bronchodilators, including ß-adrenoreceptors, antimuscarinic drugs, and theophyllines

PDE4 inhibitors

Corticosteroids

Antibiotics, COVID, pneumococci, flu vaccines

Mucolytic agents

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Be careful with O2 as it can change pH levels and pressure of lung.

If O2 levels are too low, it can cause breathing mechanism to be confused --> slower breathing --> can stop breathing

CO: if patients have hypercapnia

CO2 insensitivity in blue bloaters

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Alpha1-antitrypsin replacement

Right sided heart failure

Kidney disease

Secondary polycythaemia→requires venesection (removing blood from the circulatory system through a cut) if packed cell volume is >55%

Sensation of breathlessness→short-acting sedation (administering sedating drugs) e.g. sublingual lorazepam/opiates are palliative (relieving pain) measure for intractable (uncontrollable) dyspnea. Others: breathing techniques and fan therapy

Harder to travel with airplanes

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younger patients are more likely to get lung transplant as they have longer life expectancy

Lung allocation score: A scoring system used to prioritize patients for lung transplants based on medical urgency and likelihood of transplant success. 1-100

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hypertension

diabetes

cor pulmonale

kidney disease

More failures, not possible to get lung transplant