Pulmonary emphysema is an abnormal enlargement of the airspaces in the lungs caused by destruction of alveolar walls. It affects over 210 million people worldwide and is primarily caused by smoking. The main types are centriacinar, panacinar, and paraseptal emphysema. Patients present with shortness of breath but without sputum production. Diagnosis can be made through chest imaging that shows hyperinflated lungs and loss of markings. Emphysema results from an imbalance between proteases that break down lung tissue and antiproteases that inhibit them.

1. Pulmonary EmphysemaPulmonary Emphysema
Man B Paudyal
IOM
email : paudyalman82@gmail.com

2. Emphysema
Definition: 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 causes dilation of air spaces
by destruction of alveolar wall, leading to
collapse of alveoli during expiration

3. Normal acinusNormal acinus

4. Lung comparisonLung comparison

5. EpidemiologyEpidemiology
 Approximately 210 million people are affected
worldwide leading to 3 million deaths annually.
The cumulative effect of smoking and other
environmental risk factors.
 incidence,Men > women but with increased
smoking and environmental risk factor exposure
among women, the incidence is now equal
between the sexes. Patients with genetic risk
factors such as alpha-1-antitrypsin deficiency
may present earlier according to phenotype.
Risk factors include:
smoking: by far the most common
alpha-1-antitrypsin (AAT) deficiency
intravenous injection of methylphenidate (Ritalin
lung

6. classificationclassification
Types of emphysema
1.Centriacinar
2. Panacinar
3. Paraseptal [Distal acinar]
4. Mixed & unclassified [Irregular]

7. 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]
Panacinar Emphysema:
• Whole of Acinus uniformly affected
• Lower lobes severely involved
• Association:
… A1AT deficiency
… Cigarette smokers

8. Centriacinar emphysemaCentriacinar emphysema. Central areas. Central areas
show marked emphysematous damage (E),show marked emphysematous damage (E),
surrounded by relatively spared alveolarsurrounded by relatively spared alveolar
spaces. B,spaces. B, Panacinar emphysemaPanacinar emphysema involvinginvolving
the entire pulmonary lobulentriathe entire pulmonary lobulentria

9. 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

10. 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

11. Pathogenesis emphysemaPathogenesis emphysema

12. Clinical presentationClinical presentation
 The clinical features of emphysema should be distinguished from the signs
and symptoms of chronic bronchitis. Patients with emphysema are
hypocapnoeic and are often referred to as "pink puffers". This compares
with the hypercapnoea and cyanosis of chronic bronchitis with patients
referred to as "blue bloaters". In practice, features of these two syndromes
coexist as chronic obstructive pulmonary disease.
Patients typically report dyspnoea without significant sputum production.
Signs of emphysema include:
 tachypnoea
 absence of cyanosis
 pursed-lip breathing
 chest hyperinflation
 reduced breath sounds
 hyper-resonant to percussion
 cor pulmonale (late)
Emphysema is best evaluated on CT, although indirect signs can be
noticed on conventional radiography in a proportion of cases.

13. Chest radiograph
◦ increased AP diameter with flattened
diaphragms
◦ hyperinflated lungs
◦ loss of lung markings
◦ elongated heart

14. Chest Xray of emphysema patientChest Xray of emphysema patient

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