Lll

1. Pathophysiology of Pulmonary
System
Prof. Zeinab Al-Wahsh
HU
2020-2021

2. Physiology of Airway Disease
 Upper respiratory tract
 Trachea and major
bronchi
 Lower respiratory tract
 Bronchi and alveoli
 Creation of negative
pressure
 Effects of CO2/pH
 Role of inflammatory
mediators
 Increase airway
responsiveness by:
 Producing
bronchospasm
 Increasing mucus
secretion
 Producing injury to
the mucosal lining of
the airways

3. Signs and Symptoms of Pulmonary
Disease
 Dyspnea
 Subjective sensation of uncomfortable breathing
 Orthopnea
• Dyspnea when a person is lying down
Prof. Zeinab Al-Wahsh 3

4. Signs and Symptoms of Pulmonary
Disease (Cont.)
 Cough
 Acute cough
 Chronic cough
 Abnormal sputum
 Hemoptysis
 Abnormal breathing patterns:
 Kussmaul respirations (hyperpnea)
Prof. Zeinab Al-Wahsh 4

5. Signs and Symptoms of Pulmonary
Disease (Cont.)
 Hypoventilation
 Hypercapnia
 Hyperventilation
 Hypocapnia
 Cyanosis
 Clubbing
 Pain
Prof. Zeinab Al-Wahsh 5

6. Clubbing
Prof. Zeinab Al-Wahsh 6
Modified from Seidel HM et al: Mosby’s guide to physical examination, ed 7, St
Louis, 2011, Mosby.

7.  clubbing, in which there is enlargement of the
distal segment of the finger.
 It is associated with conditions of decreased
oxygenation such as bronchiectasis, cystic
fibrosis, pulmonary fibrosis, lung abscess,
and congenital heart disease.
Prof. Zeinab Al-Wahsh 7

8. Conditions Caused by
Pulmonary Disease or Injury
 Hypercapnia
 Hypoxemia
 Hypoxemia vs. hypoxia
 Ventilation-perfusion abnormalities
• Shunting
 Acute respiratory failure
Prof. Zeinab Al-Wahsh 8

9. Hypoxemia
 Hypoxemia results from
 An inadequate O2 in the air
 Disease of the respiratory system
 Dysfunction of the neurological system
 Alterations in circulatory function
 Mechanisms
 Hypoventilation
 Impaired diffusion of gases
 Inadequate circulation of blood through the pulmonary
capillaries
 Mismatching of ventilation and perfusion

10. Manifestations of Hypoxemia
 Mild Hypoxemia
 Metabolic acidosis
 Increase in heart rate
 Peripheral vasoconstriction
 Diaphoresis
 Increase in blood pressure
 Slight impairment of mental performance

11. Chest Wall Disorders
 Chest wall restriction
 Compromised chest wall
• Deformation, immobilization, and/or obesity
 Flail chest
 Instability of a portion of the chest wall
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12. Flail Chest
Prof. Zeinab Al-Wahsh 12

13. Pleural Abnormalities
 Pneumothorax
 Open pneumothorax
 Tension pneumothorax
 Spontaneous (primary) pneumothorax
 Secondary pneumothorax
Prof. Zeinab Al-Wahsh 13

14. Pulmonary Disorders
 Restrictive lung diseases
 Aspiration
• Passage of fluid and solid particles into the lungs
 Atelectasis
• Compression atelectasis
• Absorption atelectasis
• Surfactant impairment
 Bronchiectasis
• Persistent abnormal dilation of the bronchi
Prof. Zeinab Al-Wahsh 14

15. Pulmonary Disorders (Cont.)
 Restrictive lung diseases
 Bronchiolitis
• Inflammatory obstruction of the small airways
• Most common in children
• Occurs in adults with chronic bronchitis, in association with a
viral infection, or with inhalation of toxic gases
 Pulmonary fibrosis
• Idiopathic
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16. Pulmonary Disorders (Cont.)
 Restrictive lung diseases (Cont.)
 Pulmonary edema
• Excess water in the lungs
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17. Cor pulmonale
 Cor pulmonale, also called
pulmonary heart disease, consists
of right ventricular enlargement
and failure.
Prof. Zeinab Al-Wahsh 17

18. Atelectasis
 Definition
 The incomplete expansion of a lung or portion of a
lung
 Causes
 Airway obstruction
 Lung compression such as that occurs in
pneumothorax or pleural effusion
 Increased recoil of the lung due to loss of pulmonary
surfactant

19. Pleural Effusion
 Pleural Effusion can be caused by
transudate, exudate, or other fluid.
Prof. Zeinab Al-Wahsh 19

20. Pulmonary Edema
Prof. Zeinab Al-Wahsh 20

21. Pulmonary Disorders
 Restrictive lung diseases (Cont.)
 Acute lung injury (ALI)/Acute respiratory distress
syndrome (ARDS)
• Characterized by acute lung inflammation and diffuse
alveolocapillary injury
• Injury and inflammation to the alveocapillary membrane
 Pulmonary edema
• Three phases:
 Exudative
 Proliferative
 Fibrotic
Prof. Zeinab Al-Wahsh 21

22. Pulmonary Disorders (Cont.)
 Restrictive lung diseases (Cont.)
 Acute lung injury (ALI)/Acute respiratory distress
syndrome (ARDS) (Cont.)
• Manifestations:
 Dyspnea and hypoxemia
 Hyperventilation and respiratory alkalosis
 Decreased tissue perfusion, metabolic acidosis, and organ
dysfunction
 Increased work of breathing, decreased tidal volume, and
hypoventilation
 Hypercapnia, respiratory acidosis
 Respiratory failure, decreased cardiac output, hypotension, and
death
Prof. Zeinab Al-Wahsh 22

23. Pulmonary Disorders (Cont.)
 Acute respiratory distress syndrome (ARDS) is
characterized by damage that is done to the
alveolar capillary membrane and causes severe
pulmonary edema. The most common cause of
ARDS is either sepsis or multiple trauma.
Macrophages, neutrophils, complement, and
endotoxins are all important mediators.
 Acute lung injury (ALI)/Acute respiratory distress
syndrome (ARDS) (Cont.)
 Diagnosis is based on a history of the lung injury,
physical examination, analysis of blood gases, and
radiologic examination
Prof. Zeinab Al-Wahsh 23

24. Pulmonary Disorders (Cont.)
 Obstructive lung diseases
 Airway obstruction that is worse with expiration
 Common signs and symptoms
• Dyspnea and wheezing
 Common obstructive disorders
• Asthma
• COPD
• Emphysema
• Chronic bronchitis
Prof. Zeinab Al-Wahsh 24

25.  Asthma is caused by increased bronchial smooth
muscle spasm and increased vascular
permeability.
 IgE is the major factor. T
 here is increased capillary permeability.
 Inflammatory mediators cause vasodilation,
increased capillary permeability, mucosal
edema, bronchial smooth muscle contraction
(bronchospasm), and mucus secretion from
mucosal goblet cells with narrowing of the
airways and obstruction to airflow
Prof. Zeinab Al-Wahsh 25

26. Factors Contributing to the
Development of an Asthmatic Attack
 Allergens
 Respiratory tract infections
 Exercise
 Drugs and chemicals
 Hormonal changes and emotional upsets
 Airborne pollutants
 Gastroesophageal reflux

27. Pulmonary Disorders (Cont.)
 Obstructive lung diseases: Asthma
 Chronic inflammatory disorder of the airways
 Inflammation results from hyperresponsiveness of
the airways
 Can lead to obstruction and status asthmaticus
 Symptoms include expiratory wheezing, dyspnea,
and tachypnea
 Peak flow meters, corticosteroids, beta agonists,
and anti-inflammatories used to treat
Prof. Zeinab Al-Wahsh 27

28. Pulmonary Disorders (Cont.)
 Obstructive lung diseases: COPD
 Characterized by persistent airflow limitation
 Usually progressive
 Most common chronic lung disease in world
 Risk factors
• Tobacco smoke
• Occupational dusts and chemicals
• Air pollution
• Any factor affecting lung growth during gestation and
childhood
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29. Pulmonary Disorders (Cont.)
 Obstructive lung diseases: Chronic bronchitis
 Hypersecretion of mucus and chronic productive cough
that lasts for at least 3 months of the year and for at least
2 consecutive years
 Inspired irritants increase mucus production and the size
and number of mucous glands
 The mucus is thicker than normal
 Bronchodilators, expectorants, and chest physical
therapy used to treat
Prof. Zeinab Al-Wahsh 29

30. Pulmonary Disorders (Cont.)
 Obstructive lung diseases: Emphysema
 Abnormal permanent enlargement of the gas-exchange
airways accompanied by destruction of alveolar walls
without obvious fibrosis
 Inherited deficit of α1-antitrypsin
 Loss of elastic recoil
Prof. Zeinab Al-Wahsh 30

31. Characteristics of Type A Pulmonary
Emphysema
 Smoking history
 Age of onset: 40 to 50 years
 Often dramatic barrel chest
 Weight loss
 Decreased breath sounds
 Normal blood gases until late in disease
process
 Cor pulmonale only in advanced cases
 Slowly debilitating disease

32. Pulmonary Disorders (Cont.)
 Respiratory tract infections: Acute bronchitis
 Acute infection or inflammation of the airways or bronchi
 Commonly follows a viral illness
 Acute bronchitis causes symptoms similar to those of
pneumonia but does not demonstrate pulmonary
consolidation and chest infiltrates
Prof. Zeinab Al-Wahsh 32

33. Characteristics of Type B Chronic
Bronchitis
 Smoking history
 Age of onset 30 to 40 years
 Barrel chest may be present
 Shortness of breath, a predominant early
symptom
 Rhonchi often present
 Sputum frequent, an early manifestation

34. Pulmonary Disorders (Cont.)
 Respiratory tract infections: Pneumonia
 Lower respiratory tract infection
 Caused by bacteria, viruses, fungi, protozoa, or
parasites
 Healthcare acquired (HCAP) or community acquired
(CAP)
Prof. Zeinab Al-Wahsh 34

35. Pulmonary Disorders (Cont.)
 Respiratory tract infections: Pneumonia (Cont.)
 Pneumococcal
• Most common and most lethal
• Intense inflammatory response
 Viral
• Seasonal and usually self-limiting
 Usually preceded by viral URI
Prof. Zeinab Al-Wahsh 35

36. Pulmonary Disorders (Cont.)
 Respiratory tract infections
 Tuberculosis
• Mycobacterium tuberculosis
• Acid-fast bacillus
• Airborne transmission
• Tubercle formation
• Positive tuberculin skin test (PPD)
Prof. Zeinab Al-Wahsh 36

37. Pulmonary Disorders (Cont.)
 Pulmonary vascular disorders: Pulmonary
embolus
 Occlusion of a portion of the pulmonary vascular bed by
a thrombus, embolus, tissue fragment, lipids, or an air
bubble
 Pulmonary emboli commonly arise from the deep veins
in the lower leg
 Venous stasis, hypercoagulability, and injuries to the
endothelial cells that line the vessels
Prof. Zeinab Al-Wahsh 37

38. Pulmonary Embolism
 Development
 A blood-borne substance lodges in a branch of the
pulmonary artery and obstructs the flow
 Types
 Thrombus: arising from DVT
 Fat: mobilized from the bone marrow after a fracture
or from a traumatized fat depot
 Amniotic fluid: enters the maternal circulation after
rupture of the membranes at the time of delivery

39. Pulmonary Disorders (Cont.)
 Pulmonary vascular disorders: Pulmonary artery
hypertension
Mean pulmonary artery pressure 5 to 10 mm
Hg above normal or above 20 mm Hg
Primary pulmonary hypertension
•Idiopathic
Diseases of the respiratory system and
hypoxemia are more common causes
Prof. Zeinab Al-Wahsh 39

40. Pulmonary Disorders (Cont.)
 Pulmonary vascular disorders: Pulmonary artery
hypertension (Cont.)
 Classifications:
• Pulmonary arterial hypertension
• Pulmonary venous hypertension
• Pulmonary hypertension due to a respiratory disease or
hypoxemia
• Pulmonary hypertension due to thrombotic or embolic disease
• Pulmonary hypertension due to diseases of the pulmonary
vasculature
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41. Pulmonary Hypertension
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42. Pulmonary Disorders (Cont.)
 Pulmonary vascular disorders: Cor
pulmonale
Pulmonary heart disease
•Right ventricular enlargement
•Secondary to pulmonary hypertension
•Pulmonary hypertension creates
chronic pressure overload in the right
ventricle
Prof. Zeinab Al-Wahsh 42

43. Pulmonary Disorders (Cont.)
 Malignancies of the respiratory tract
Laryngeal
•Forms:
Carcinoma of the true vocal
cords (most common)
Supraglottic
Subglottic rare
Prof. Zeinab Al-Wahsh 43

44. Laryngeal Cancer
Prof. Zeinab Al-Wahsh 44
Redrawn from del Regato JA et al: Ackerman and del Regato’s cancer, ed 2, St Louis, 1985, Mosby.

45. Pulmonary Disorders (Cont.)
 Malignancies of the respiratory tract
 Lung (bronchogenic)
• Most common cause is cigarette smoking
• Heavy smokers have a 20-times greater chance of
developing lung cancer than nonsmokers
• Smoking is related to cancers of the larynx, oral
cavity, esophagus, and urinary bladder
• Environmental or occupational risk factors are
also associated
Prof. Zeinab Al-Wahsh 45

46. Pulmonary Disorders (Cont.)
 Malignancies of the respiratory tract (Cont.)
 Lung
• Types:
 Non–small cell cancer:
– Squamous cell carcinoma
– Adenocarcinoma
– Large cell carcinoma
 Small cell cancer—from neuroendocrine tissue
Prof. Zeinab Al-Wahsh 46