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Target: UG medical students.

Published in: Health & Medicine
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  2. 2. Clinical presentations• Dyspnoea• Recurrent respiratory infections• Right heart failure
  3. 3. Main pulmonary changeIncreased air space in the lungs
  4. 4. 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
  5. 5. Emphysema Emphysema causes dilation of airspaces by destruction of alveolar wall, leading to collapse of alveoli during expiration
  6. 6. Emphysema & Overinflation• Emphysema: Increased air space with destruction• Overinflation: Increased air space without destruction
  7. 7. 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.
  8. 8. A lung with emphysema shows increasedanteroposterior (AP) diameter, increasedretrosternal airspace, and flatteneddiaphragms on lateral chest radiograph.
  9. 9. Severe bullous disease observed on CT scan in a patient with COPD
  10. 10. Classification: Types of emphysema1. Centriacinar2. Panacinar3. Paraseptal [Distal acinar]4. Mixed & unclassified [Irregular]
  11. 11. RB1 Normal Acinus Alveoli
  12. 12. A RB CentrilobularTB Panlobular Paraseptal Irregular
  13. 13. 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]
  14. 14. CENTRIACINARFIGURE 15-7 A, Centriacinar emphysema. Central areasshow marked emphysematous damage (E), surrounded byrelatively spared alveolar spaces. B, Panacinar emphysemainvolving the entire pulmonary lobule.
  16. 16. Panacinar Emphysema:• Whole of Acinus uniformly affected• Lower lobes severely involved• Association: … A1AT deficiency … Cigarette smokers
  17. 17. PANACINAR
  18. 18. Paraseptal (Distal Acinar)• Localized along pleura - peripheral part of the acinus• Predisposes to spontaneous peumothorax• Adjacent to foci of fibrosis• Least common
  21. 21. Microscopy of emphysema
  22. 22. Emphysema - Microscopy
  23. 23. Pathogenesis• Protease and antiprotease theory AAT, A1MG• Oxidant-antioxidant imbalance SOD, Glutathione
  24. 24. 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
  25. 25. Pathophysiology
  26. 26. Pathophysiology• Expiratory narrowing of bronchioles > Air flow obstruction > underventilation• Mismatch between ventilation & perfusion• Can lead to chronic cor pulmonale
  27. 27. Etiology• Cigarette smoking [20 - 40% smokers]• Air pollution• Alpha-1-antitrypsin deficiency• Inherited diseases ( Rare ) * Cutis laxa * Marfan’s syndrome * Menke’s syndrome
  28. 28. Cutis Laxa
  29. 29. Marfan’s syndrome
  30. 30. Elher Danlos syndrome
  31. 31. Menke’s syndrome
  32. 32. Other types of emphysema• Compensatory emphysema• Senile emphysema• Obstructive overinflation• Bullous emphysema• Interstitial emphysema: … Trauma to chest wall … Severe cough
  33. 33. Bullae• Def: Subpleural, air-filled cystic areas• Size: >1cm• Location: Anterior margin & Apices• Complication: Rupture > Pneumothorax
  34. 34. Emphysematous Bullae
  35. 35. Fig-1 Bullous emphysema with large subpleural bullae (upper left)Fig-2 Chronic obstructive pulmonary disease (COPD). Gross pathology of a patient with
  36. 36. Irregular Emphysema with Bullae
  37. 37. Atelectasis of right lung with shift in mediastinum
  38. 38. Clinical picture• Dysponea• Cough with or without expectoration• Wheezing• Loss of weight• Peptic ulceration• Hypercapnia > changes in central nervous system• Barrel chest
  39. 39. Barrel chest
  40. 40. Obstructive Pulmonary diseases• Disorders Associated with Airflow Obstruction• Chronic bronchitis, Emphysema, Asthma, Bronchiectasis & Bronchiolitis come under this category
  41. 41. 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.
  42. 42. 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
  43. 43. Figure 15-9 Schematic representation of evolution of chronic bronchitis (left) and emphysema (right).
  44. 44. 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
  45. 45. “Pink Puffer” Emphysema Thin Dysponea < Vital capacity > Lung volume
  46. 46. “Blue Bloater” – Chronic bronchitis
  47. 47. “Pink Puffers & Blue Bloaters”
  48. 48. 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
  49. 49. E N D