Chronic Obstructive Pulmonary Disease

1. Shree b.m.patil medicalcollege,bijapur
Department of Radiology
PRESENTED BY-
-
Ravi Prakash

2. Chronic obstructive pulmonary
disease.
Disease state characterized by airflow
limitation that is not fully reversible.
A. Chronic bronchitis- a clinically defined
condition with chronic cough and phlegm.
B. Emphysema- an anatomically defined
condition characterized by destruction &
enlargement of lung alveoli.

3. Chronic bronchitis:-
condition associated with excessive
tracheobronchial mucus production
to cause cough with expectoration
for at least 3 month of year for
more than 2 year.
Aetiology-
 cigarette smoking
 air pollution
 occupational hazards -
cotton mill , coal mining , rubber
industry , gold mining
 familial factor
 genetic factor
 infection-by rhinovirus , strep

4. Pathophysiology-
 Hypertrophy & hyperplasia of mucus producing
gland
 Reduction in caliber of air passage

5. airflow obstruction

6. Clinical feature-
Cough
Sputum production
Exertional dyspnoea
Breathlessness relatively late onset
Percussion note- resonant over
lung field
Auscultation- vesicular breathing,
rhonchi, crepitation
Blue bloaters

7. Gold criteria-
GOLD
STAGE
SEVERITY SYMPTOM SPIROMETRY
0 At risk Chronic cough , sputum
production
normal
1 mild With or without chronic cough or
sputum production
FEV1/FVC<0.7
FEV1>=80%predi
cted
11 moderat
e
With or without chronic cough or
sputum production
FEV1/FVC<0.7
50%<=FEV1<80%
predicted
111 severe With or without chronic cough or
sputum production
FEV1/FVC<0.7
30%<=FEV1<50%
predicted
1V Very
severe
With or without chronic cough or
sputum production
FEV1/FVC<0.7
FEV1<=30%predi
cted
Or

8. Investigation-
PULMONARY FUNCTION TEST
FEV1-reduced
VC-reduced
RV-increased
TLC-increased
Gas transfer-decrease or normal
Arterial blood gas analysis-
pao2-decreased
Paco2-increased

9. Radiological studies-
CHEST X-RAY:-
a. Bronchial wall
thickening
b. Increase in lung
marking
c. Small,ill defined
opacity anywhere
in lung
d. Occasionally a
wide alteration in
lung marking may
be seen where the
normal vascular
pattern is partly

10. Linear shadow
Increase peribronchial marking
especially at the base due to
thickened bronchial &
peribronchial tissue

11. Bronchogram-
 dilatation of
bronchial gland
leading to irregular
out pouching from
bronchial lumen
mostly often seen in
wall of major bronchi.
 abrupt termination of
smaller branch of
bronchi with square
& truncated ending
 bronchiolar spasm
 increased secretion

12. Complication-
Mismatch of ventilation &
perfusion
Co2 narcosis Respiratory
failure
Hypoxaemia
hypercarbia
Pulmonary
vasoconstriction
Pulmonary
hypertension
Right ventricular
hypertrophy
Right
ventricular
failure
Increased
erythropoisis
Sec.
polycythe
mia
Desaturation
of Hb
cynaosis

13. Treatment-
1. general measure-
 Smoke caessation
 Regular exercise
 Weight loss
2.bronchodialator-
 Inhalation of b2 agonist-salbutamol 200mcg
Terbutalin 600mcg 6th
hourly
3.glucocorticoides-
 improve the gas exchange to some extent

14. 4.oxygen-
 Supplemental o2 by nasal catheter & through
face mask
 Mainly for exertional or nocturnal hypoxaemia
6.antibiotic-
If any infection is there-
Doxycycline,co-trimoxazole,amoxycillin-
clavulanate,gatifloxacin,iv azithromycin ,
ceftriaxone,cefotaxime
5.Others
 N-acetyl cysteine-mucolytic & antioxidant

15. Emphysema
Distension of air spaces
distal to terminal bronchiole
with destruction of the
alveolar septa.
Predisposing factors-
 smoking
 Environmental pollution
 Occupational exposure-cadmium,
furnace blower
 Alpha1antitrypsin deficiency

16. Type-
a. centriacinar- destruction & enlargement of
central & proximal part of respiratory
unit acinus.
Upper lobe and apices
Seen in male smokers
b.panacinar- uniform destruction & enlargement
of acinus
Mainly involve lower basal zone
Seen in alpha 1 antitrypsin def
patient
c.paraseptal- only distal acinus involve
Found near pleura

17. Type..

18. 1.compensatory-
 Normal lung tissue undergoes compensatory
mechanism for an extensive damage to other
lung or part of the same lung.
 Hyper resonant percussion note.
 Increase breath sound.
2.subcutaneous-
 seen in case of penetrating chest injury
 Rib fracture
 Intercostals tube introduction

19. 3.Mediastinal emphysema-
 Vertical translucent streak , separating & outlining
the soft tissue layers & structure of mediastinum.
 Air often separates the parietal pleura from the
mediastinum & pleura may then be visible as a
thin hair line running parallel to mediastinum.
 Air may be seen in neck also. Due to escape of air
rapidly into mediastinum after rupture of over
distended alveoli.
 On auscultation crunching sound heard.

20. Pathogenesis-
Cigarette
smoke
Inflammatory
cell
recruitment
neutrophil
macrophage
Serin
e
prote
inase
s
ECM
degradati
on, lung
tissue
destructio
n
Cyste
ine
protei
nases
Proteina
se
inhibitor
s

21. Clinical feature-
Progressive
Exertional
breathlessness
minimum
cough &
expectoratio
n
Weakness
lethargy
Weight
loss
anorexia

22. SIGN..
Inspection & palpation-
 Tachypnoeic
 Hypertrophy of accessory muscle of
respiration
 Purse lip breathing
 Chest bowel shaped
 AP diameter- increased
 AP:TD –altered(normal-5:7)
 Angle of Luis-prominent
 Sub costal angle widened(normal 70’)
 Apical impulse is usually invisible or
feeble.

23. Percussion-
 hyper resonant over lung field area
 cardiac dullness decreases
 liver dullness pushed down or absent if right
side involved
Auscultation-
 Breath sound –decreases
 Prolong expiration
 Pink puffers

24. Difference In chronic bronchitis &
emphysema.
feature chronic bronchitis emphysema
cough Before dyspnoea starts After dyspnoea starts
sputum Copious , purulent Scanty , mucoid
dyspnoea mild severe
cynosis present absent
infection common Less common
Chest x-ray Increased bronchovascular
marking , cardiomegaly
Feature of hyperinflation ,
bullae,tubular heart
Pulmonary
hypertension
Moderate to severe mild
Diffusing
capacity
normal decreased

25. Investigation-
PULMONARY FUNCTION TEST
FEV1 -decreases
VC -decreases
FEV1/VC -decreases
PEF -decreases
TLC -increases
RV -increases

26. CHEST X-RAY-
 Irregular area of
radiolucency related to
tissue loss
 Increase in retero
sternal air space

27. Alteration in vascular pattern
Presence of over inflation
Increased lung volume

29. Bullae-
 Multiple & small-
May be localized to a lobe
or may be B/L
Upper lobe more often
affected
 Giant bulla-
Rib interspaced is
widened in region of giant
bulla
Neighboring normal
tissue is compressed with
vessels crowded together

30. CT SCAN Finding:-
it permit the direct identification of destroyed lung
tissue with high precision.
It shows-
 Area of decreased attenuation without visible walls
 Pruning of pulmonary vessels
 Distortion of pulmonary vessels
 Decrease lung tissue gradient

31. Centrilobular-
lucent region initially
surrounded by normal
lung parenchyma but
become confluent
along with obliteration
of peripheral vascular
as disease progresses.
Panlobular-
Widespread area of
low attenuation usually
seen accompanied by
diffuse vascular
distortion.

32. Nuclear imaging-
 Functional evaluation of the lungs can be
carried out by using xenon-133 (133 Xe) lung
ventilation scintigraphy before and after lung-
volume–reduction surgery (LVRS) in patients with
pulmonary emphysema.
Xenon-133 washout curves during lung
scintigraphy exhibit a biphasic pattern:
(1) the first component corresponds to an initial
rapid phase in washout that reflects emptying
of the large airways, and
(2) the second component, reflects a slower
phase of washout that is attributed to gas
elimination in the small airways.

33. Complication-
pulmonary bullae
Significant Weight loss
Respiratory failure
Pulmonary hypertension-late
Right heart failure-late

34. Emphysema with chronic bronchitis-
Radiological finding--
 Decrease in size & no. Of small vascular marking
specially in middle & outer 1/3rd of lung
 Main pulmonary arteries are enlarged making hilar
shadow prominent
 May be barrel shaped chest with increase in AP
diameter & anterior bowing of sternum
 Ant mediastinal space is usually increased in depth

35.  Heart shadow is often long,narrow &
cardiothoracic ratio may change to 1:3 or 1:4.
 Lung fields are seen more translucent
 Increased vol of lung results in flattening of
contour of diaphragm
 Best seen in lateral projection & level is
lowered below the 11th rib.

36. Treatment-
cessation of smoking
Antibiotics
IV alpha1 AT therapy
Vaccination against
influenza & pneumococcal
Low dose benzodiazepine
i.e. alprazolam

37. Mechanical ventilatory support-
Noninvasive PPV-
paco2 more than 45 mmhg
Acidosis
Invasive PPV-
Severe respiratory distress
Severe acidosis
Severe hypoxia
NIPPV failure

38. Surgical-
A. bullectomy
B. Lung volume reduction surgery-
Not done if significant pleural disease
PASPmore than 45 mm mg
C.Lung transplantation-
Age should be less than 65 yrs
Free from liver cardiac renal disease

39. REFERENCES….
Harrison’s principles of internal medicine
Manual of practical medicine-R Alagappan
Fraser& pare’s diagnosis of diseases of chest
Roentgenlogic diagnosis bysaunder’s
CT & MRI imaging of whole body-Haaga,Tanzien,Gilkeson
Internet