Obstructive and restrictive pulmonary diseases can be categorized based on pulmonary function tests. Obstructive diseases like emphysema and chronic bronchitis involve airflow limitation due to airway obstruction. Restrictive diseases like pulmonary fibrosis involve reduced lung expansion and capacity. Chronic obstructive pulmonary disease (COPD) encompasses chronic bronchitis and emphysema, both of which involve irreversible airway obstruction. Emphysema is defined as abnormal enlargement of airspaces distal to terminal bronchioles due to alveolar wall destruction. The main types are centriacinar and panacinar emphysema. Emphysema results from an imbalance between proteases and antiproteases degrading lung tissue in heavy smokers.

1. Obstructive and RestrictiveObstructive and Restrictive
PulmonaryPulmonary diseasedisease
BYBY
PINAK SAINIPINAK SAINI

2. Diffuse pulmonary DiseaseDiffuse pulmonary Disease
• On the basis of deranged pulmonary physiology, i.e. based onOn the basis of deranged pulmonary physiology, i.e. based on
pulmonary function tests,pulmonary function tests,
Two categories:Two categories:
•(1)(1) obstructive diseaseobstructive disease (or(or airway diseaseairway disease), characterized by an), characterized by an
increase in resistance to airflow owing to partial or complete obstructionincrease in resistance to airflow owing to partial or complete obstruction
at any level, from the trachea and larger bronchi to the terminal andat any level, from the trachea and larger bronchi to the terminal and
respiratory bronchiolesrespiratory bronchioles

3. •(2)(2) restrictive disease,restrictive disease, ..
 Characterized by reduced expansion of lung parenchyma, withCharacterized by reduced expansion of lung parenchyma, with
decreased total lung capacitydecreased total lung capacity
 Although many conditions have both obstructive and restrictiveAlthough many conditions have both obstructive and restrictive
components.components.

4. Obstructive restrictive
characterized by limitation of airflow due
to partial or complete obstruction
characterized by reduced expansion of
lung parenchyma accompanied by
decreased total lung capacity.
Eg are emphysema, chronic bronchitis,
bronchiectasis, and asthma
Eg idiopathic pulmonary fibrosis,
interstitial pneumonia,
Pneumoconiosis,Sarcoidosis; and chest
wall neuromuscular diseases
total lung capacity normal decreased
decreased expiratory flow rate Normal or reduced

6. Chronic Obstructive Pulmonary Disease (COPD)Chronic Obstructive Pulmonary Disease (COPD)
 It is a chronic progressive disorder of airway obstruction with a little orIt is a chronic progressive disorder of airway obstruction with a little or
no reversibility.no reversibility.
COPD includes –COPD includes –
 Chronic BronchitisChronic Bronchitis
 EmphysemaEmphysema

7. CHRONIC BRONCHITISCHRONIC BRONCHITIS
Bronchitis is an inflammation of the bronchi causing excessive mucousBronchitis is an inflammation of the bronchi causing excessive mucous
production and swelling of the bronchial walls.production and swelling of the bronchial walls.
Defn : -Defn : - It is defined clinically as persistence of cough withIt is defined clinically as persistence of cough with
expectoration{sputum} at least for 3 months in at least 2 consecutiveexpectoration{sputum} at least for 3 months in at least 2 consecutive
years. (Provided other causes of cough has been ecluded)years. (Provided other causes of cough has been ecluded)

8. ETIOPATHOGENESISETIOPATHOGENESIS : -: -
•It is more common in males of 30 to 40 yrs.It is more common in males of 30 to 40 yrs.
Two main etiological factorsTwo main etiological factors
1. Primary or initiating factor1. Primary or initiating factor
•Chronic inhalation of tobacco smoke and atmospheric pollutionChronic inhalation of tobacco smoke and atmospheric pollution
2. Contributory factor - Infections : - Like bacterias, viral & fungal2. Contributory factor - Infections : - Like bacterias, viral & fungal

9. Pathogenesis
Hypersecretion of mucus
Infection
Bronchospasm
Continued and repeated
injury (smoking)
Bronchiolar and bronchial injury
Reversible obstruction in bronchioles and small bronchi
Chronic bronchitis
Continued and repeated
infection

10. PATHOLOGYPATHOLOGY : -: -
GROSS :GROSS :
Bronchial walls are thickened, oedematous, hyperaemic causingBronchial walls are thickened, oedematous, hyperaemic causing
bronchial lumens to be narrowed & filled with secretions.bronchial lumens to be narrowed & filled with secretions.

11. Microscopic :Microscopic :
 Hypertrophy{inc. size of cell} of bronchial mucous glands &Hypertrophy{inc. size of cell} of bronchial mucous glands &
Increased in goblet cellsIncreased in goblet cells
 Hypersecretion of mucusHypersecretion of mucus
 Inflammation – hyperaemia{excess of blood in the vessels} &Inflammation – hyperaemia{excess of blood in the vessels} &
oedema of mucous membraneoedema of mucous membrane
 FibrosisFibrosis
 Bronchial squamous metaplasia and dysplasia{enlargement ofBronchial squamous metaplasia and dysplasia{enlargement of
organ by proliferation of cell} (smokers).organ by proliferation of cell} (smokers).


13. Clinical findingsClinical findings
i. Cough, sputum production, dyspnea, frequent infectionsi. Cough, sputum production, dyspnea, frequent infections
ii. Hypoxia, cyanosis{blue discolouration of skin}ii. Hypoxia, cyanosis{blue discolouration of skin}
ComplicationsComplications
i. Increased risk for recurrent infectionsi. Increased risk for recurrent infections
ii. Pulmonary HTN leading to right heart failure (cor pulmonale)ii. Pulmonary HTN leading to right heart failure (cor pulmonale)
iii. Lung canceriii. Lung cancer

14. EmphysemaEmphysema
Definition:Definition:
It is defined as abnormal permanent enlargement of air spaces distalIt is defined as abnormal permanent enlargement of air spaces distal
to the terminal bronchioles with destruction of alvelolar walls.to the terminal bronchioles with destruction of alvelolar walls.

15. Types of EmphysemaTypes of Emphysema
There are 4 major types of emphysemaThere are 4 major types of emphysema
a.a. Centriacinar ( centrilobular)Centriacinar ( centrilobular)
b.b. Panacinar (Panlobular)Panacinar (Panlobular)
c.c. Paraseptal (Distal acinar)Paraseptal (Distal acinar)
d.d. Irregular emphysemaIrregular emphysema
 This classification gives clue to etiology of the emphysema.This classification gives clue to etiology of the emphysema.
 Only the first two cause clinically significant airflow obstructionOnly the first two cause clinically significant airflow obstruction
 Centriacinar emphysema is far more common than the panacinarCentriacinar emphysema is far more common than the panacinar
form, constituting more than 95% of cases.form, constituting more than 95% of cases.

16. 1.1. Centriaciner emphysema –Centriaciner emphysema –
 Central or proximal parts of the acini{cluster of cell}, formed byCentral or proximal parts of the acini{cluster of cell}, formed by
respiratory bronchioles, are affected, whereas distal alveoli arerespiratory bronchioles, are affected, whereas distal alveoli are
spared .spared .
 Thus, both emphysematous and normal airspaces exist within theThus, both emphysematous and normal airspaces exist within the
same acinus and lobule.same acinus and lobule.
 The lesions are more common and usually more severe in theThe lesions are more common and usually more severe in the
upper lobes.upper lobes.
 Centriacinar type of emphysemaCentriacinar type of emphysema
usually occurs in heavy smokers.usually occurs in heavy smokers.
 This is the commonest typeThis is the commonest type

17. 2. Panacinar emphysema –2. Panacinar emphysema –
 Whole acinus is involvedWhole acinus is involved
 Here, the acini are uniformly enlarged from the level of respiratoryHere, the acini are uniformly enlarged from the level of respiratory
bronchioles to the terminal blind alveoli.bronchioles to the terminal blind alveoli.
 This type of emphysema are more common in the lower zones andThis type of emphysema are more common in the lower zones and
is associated with alpha -1 AT{antitrypsin} deficiency.{it decreasedis associated with alpha -1 AT{antitrypsin} deficiency.{it decreased
activiyi of blood or lungs}activiyi of blood or lungs}

19. Centriacinar emphysema, sparing the
alveoli
Panacinar emphysema

20. 3. Paraseptal(Distal acinar emphysema)3. Paraseptal(Distal acinar emphysema)
 Here, only the distal part of acinar are involved .Here, only the distal part of acinar are involved .
 This type of emphysema lies very close to pleura and frequently leadsThis type of emphysema lies very close to pleura and frequently leads
to spontaneous pneumothorax(presence of air or gas in the cavity into spontaneous pneumothorax(presence of air or gas in the cavity in
lungs).lungs).
 It occurs adjacent to the area of fibrosis or atelectasis(collapse of lungs)It occurs adjacent to the area of fibrosis or atelectasis(collapse of lungs)
 It is more common in the upper half of the lungs.It is more common in the upper half of the lungs.

21. Irregular emphysema –Irregular emphysema –
 Here the acinus is irregularly involved and always associated withHere the acinus is irregularly involved and always associated with
scarring.scarring.
 It is asymptomatic.It is asymptomatic.
Conditions related to emphysema:Conditions related to emphysema:
Compensatory emphysemaCompensatory emphysema
 compensatory dilatation of alveoli in response to loss of lungcompensatory dilatation of alveoli in response to loss of lung
substance elsewhere (e.g. after lobectomy)substance elsewhere (e.g. after lobectomy)
interstitial – mediastinal emphysemainterstitial – mediastinal emphysema
 entrance of air into the connective tissue of the lungs mediastinum orentrance of air into the connective tissue of the lungs mediastinum or
subcutaneous tissuesubcutaneous tissue

22. Obstructive OverinflationObstructive Overinflation
 Condition in which the lungs expands because air is trapped within itCondition in which the lungs expands because air is trapped within it
. Eg. Tumour, foreign body. Eg. Tumour, foreign body
Bullous emphysemaBullous emphysema
 Any form of emphysema that produces large subpleural blebs orAny form of emphysema that produces large subpleural blebs or
bullae (>1 cm).bullae (>1 cm).
Generally gives rise to pneumothoraxGenerally gives rise to pneumothorax

23. AetiopathogenesisAetiopathogenesis
 Smoke- chronic bronchitis- in filtration of lung tissue by inflammatorySmoke- chronic bronchitis- in filtration of lung tissue by inflammatory
cells - liberate Enzymes elastase, proteinase, etc- destruction ofcells - liberate Enzymes elastase, proteinase, etc- destruction of
elastic tissue- dilation of respiratory unit - Emphysemaelastic tissue- dilation of respiratory unit - Emphysema
 Hereditary deficiency of a1 antitrypsin- unopposed action of enzymeHereditary deficiency of a1 antitrypsin- unopposed action of enzyme
elastase- destruction of elastic tissue of lungs- dilation of respiratoryelastase- destruction of elastic tissue of lungs- dilation of respiratory
unit- Emphysemaunit- Emphysema
Therefore, emphysema is the product of an imbalance between theTherefore, emphysema is the product of an imbalance between the
proteinases and antiproteinases in favor of proteinases.proteinases and antiproteinases in favor of proteinases.

24. Pathogenesis of emphysema

25. Pathology
Gross
i. Overinflated, enlarged lungs
ii. Enlarged, grossly visible air spaces
iii. Formation of apical blebs and bullae (centriacinar type)

26. Bullous emphysema

27. smoker’s emphysema

28. Histologically:
1.Abnormal enlargement of airspaces.
2.Thinning and destruction of septal walls.
3.Compression of the septal capillaries; fibrous thickness of intima of the
pulmonary small arteries.
•Bronchiolitis involving the terminal and respiratory bronchioles.

29. Pulmonary emphysema. There is marked enlargement of airspaces, with
thinning and destruction of alveolar septa

30. Clinical findings
i. Progressive dyspnea
ii. Pursing of lips and use of accessory muscles to breathe
iii. Barrel chest
iv. Weight loss

33.  Define COPD. What are the diseases encompassingDefine COPD. What are the diseases encompassing
COPDCOPD
 Define emphysema. What are the types of emphysemaDefine emphysema. What are the types of emphysema
 Give the pathogenesis of emphysemaGive the pathogenesis of emphysema
 Write down the differences between emphysema &Write down the differences between emphysema &
chronic Bronchitischronic Bronchitis