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Emphysema
 

Emphysema

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Target: UG medical students.

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    Emphysema Emphysema Presentation Transcript

    • EMPHYSEMA[COPD - CHRONIC OBSTRUCTIVE PULMONARY DISEASES] Dr.CSBR.Prasad, M.D.
    • Clinical presentations• Dyspnoea• Recurrent respiratory infections• Right heart failure
    • Main pulmonary changeIncreased air space in the lungs
    • EmphysemaDefinition: Abnormal permanent enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls and without obvious fibrosis.Spaces in parenchyma > 1mm = Abnormal
    • Emphysema Emphysema causes dilation of airspaces by destruction of alveolar wall, leading to collapse of alveoli during expiration
    • Emphysema & Overinflation• Emphysema: Increased air space with destruction• Overinflation: Increased air space without destruction
    • Posteroanterior (PA) and lateral chest radiograph in a patientwith severe chronic obstructive pulmonary disease (COPD).Hyperinflation, depressed diaphragms, increased retrosternalspace, and hypovascularity of lung parenchyma is demonstrated.
    • A lung with emphysema shows increasedanteroposterior (AP) diameter, increasedretrosternal airspace, and flatteneddiaphragms on lateral chest radiograph.
    • Severe bullous disease observed on CT scan in a patient with COPD
    • Classification: Types of emphysema1. Centriacinar2. Panacinar3. Paraseptal [Distal acinar]4. Mixed & unclassified [Irregular]
    • RB1 Normal Acinus Alveoli
    • A RB CentrilobularTB Panlobular Paraseptal Irregular
    • Centriacinar : [ centrilobular, Proximal acinar ]• Dilatation of Respiratory Bronchiole• Upper lobes - severely involved• Can coexist with chronic bronchitis• Invariably occurs in smokers• Coal mine workers [carbon, dust]
    • CENTRIACINARFIGURE 15-7 A, Centriacinar emphysema. Central areasshow marked emphysematous damage (E), surrounded byrelatively spared alveolar spaces. B, Panacinar emphysemainvolving the entire pulmonary lobule.
    • CENTRIACINAR
    • Panacinar Emphysema:• Whole of Acinus uniformly affected• Lower lobes severely involved• Association: … A1AT deficiency … Cigarette smokers
    • PANACINAR
    • Paraseptal (Distal Acinar)• Localized along pleura - peripheral part of the acinus• Predisposes to spontaneous peumothorax• Adjacent to foci of fibrosis• Least common
    • Mixed – IRREGULAR EMPHYSEMA: • MOST COMMON • LEAST SIGNIFICANT • COMMON AROUND SCAR TISSUE • COMBINATION OF TYPES
    • Mixed [CENTRIACINAR + PARASEPTAL]
    • Microscopy of emphysema
    • Emphysema - Microscopy
    • Pathogenesis• Protease and antiprotease theory AAT, A1MG• Oxidant-antioxidant imbalance SOD, Glutathione
    • Alpha-1 Antitrypsin deficiency• 52 kD serum glycoprotein• Synthesis: liver, macrophage• Inhibits - Trypsin, Thrombin, Plasmin, Elastase• Gene: chromosome 14 [75 alleles] * Normal allele -- MM (90%) * Deficiency -- ZZ
    • Pathophysiology
    • Pathophysiology• Expiratory narrowing of bronchioles > Air flow obstruction > underventilation• Mismatch between ventilation & perfusion• Can lead to chronic cor pulmonale
    • Etiology• Cigarette smoking [20 - 40% smokers]• Air pollution• Alpha-1-antitrypsin deficiency• Inherited diseases ( Rare ) * Cutis laxa * Marfan’s syndrome * Menke’s syndrome
    • Cutis Laxa
    • Marfan’s syndrome
    • Elher Danlos syndrome
    • Menke’s syndrome
    • Other types of emphysema• Compensatory emphysema• Senile emphysema• Obstructive overinflation• Bullous emphysema• Interstitial emphysema: … Trauma to chest wall … Severe cough
    • Bullae• Def: Subpleural, air-filled cystic areas• Size: >1cm• Location: Anterior margin & Apices• Complication: Rupture > Pneumothorax
    • Emphysematous Bullae
    • Fig-1 Bullous emphysema with large subpleural bullae (upper left)Fig-2 Chronic obstructive pulmonary disease (COPD). Gross pathology of a patient with
    • Irregular Emphysema with Bullae
    • Atelectasis of right lung with shift in mediastinum
    • Clinical picture• Dysponea• Cough with or without expectoration• Wheezing• Loss of weight• Peptic ulceration• Hypercapnia > changes in central nervous system• Barrel chest
    • Barrel chest
    • Obstructive Pulmonary diseases• Disorders Associated with Airflow Obstruction• Chronic bronchitis, Emphysema, Asthma, Bronchiectasis & Bronchiolitis come under this category
    • Venn diagram of chronic obstructive pulmonary disease (COPD). Chronic obstructive lung disease is a disorder in which subsets of patients may have dominant features of chronic bronchitis,emphysema, or asthma. The result is irreversible airflow obstruction.
    • COPD• COPD: Comprises Emphysema and chronic bronchitis• Many patients have overlapping features of damage at both the acinar level (emphysema) and bronchial level (bronchitis)• Common extrinsic trigger— cigarette smoking — is implicated in both the diseases
    • Figure 15-9 Schematic representation of evolution of chronic bronchitis (left) and emphysema (right).
    • Natural history of COPD• Pathological process (for years) > clinical symptoms• Survival is variable• Respiratory failure > terminal phase of disease• 2/3 dead < 2 years• DEATH: - Respiratory acidosis and coma - Chronic cor pulmonale - Spontaneous pneumothorax
    • “Pink Puffer” Emphysema Thin Dysponea < Vital capacity > Lung volume
    • “Blue Bloater” – Chronic bronchitis
    • “Pink Puffers & Blue Bloaters”
    • Table 15-4 -- Emphysema and Chronic Bronchitis Predominant Bronchitis Predominant EmphysemaAge (yr) 40–45 50–75Dyspnea Mild; late Severe; earlyCough Early; copious sputum Late; scanty sputumInfections Common OccasionalRespiratory insufficiency Repeated TerminalCor pulmonale Common Rare; terminalAirway resistance Increased Normal or slightly increasedElastic recoil Normal LowChest radiograph Prominent vessels; large heart Hyperinflation; small heartAppearance Blue bloater Pink puffer
    • E N D