“Within the mind are all the
resources required for successful
living. Ideas are present in the
consciousness, which when released
and given scope to grow and take
shape, lead to successful events”
- Wings of Fire: An Autobiography of Dr. APJ Abdul Kalam.
“ Whether you think you can or
you can't, you are right…!”
– Henry Ford
CPC14: Mrs. PT. 64y Fem. SOB
Mrs. P.T. 64 y female, to ED at TTH.
Worsening SOB, years, worst today - At rest
• Previously SOB after exertion- COPD.
• Gradually worsening over the years, now O2 at night.
• Sputum chronic clear white, but light brown today.
• Cough - on and off for years, No wheeze, no hemoptysis,
• Chest pain worse with breathing today, fever, sweaty.
• Smoked 3 packs/day for 35 years; quit 7y ago.
Foreign travel: Norfolk Island 3wks. No health problem.
RX: Pneumonia, COPD, Emphysema, CCF
CPC: 2011 – 58M Chronic cough.
Trevor is 58 year old Caucasian man,
years of coughing. pneumonia 3 years ago; bronchitis
several times a year, Dyspnoea, Hoover’s & Campbell
sign positive, leans forward for breathing.
heavy smoker (30+/day); quit 3 years ago.
• Previous PFT: FEV1 = 1.3 FVC = 2.6 FEV1/FVC = 50%.
(too sick to perform PFT today.)
What is the significance of…
1. Leaning forward – “arms on knees”
2. Intercostal in-drawing
3. Hoover's sign ? Tracheal tug ?
4. Campbell's sign ?
1. Pathogenesis of symptoms ?
2. Further questions ?
3. Differential diagnosis ?
4. Learning issues? PFT
What is Chronic Bronchitis & Emphysema ?
Pathogenesis of COPD/CB/Emphysema ?
Smoking – Disease, Pathogenesis ?
Difference.. Obstructive / Restrictive disease ?
What findings on PFT expected ?
How is he maintaining normal pO2 & pCo2 ?
why is he pink & puffing ?
What Gross & Microscopic features in his lung ?
What complications are expected ?
Pneumoconiosis, TB, DPF,
There is only one secret to
staying young, being happy, and
achieving success - You've got to
“enjoy what you do”…!
Including studying pathology…..
COPD, Chronic lung
diseases & Pneumonia*
Dr. Shashidhar Venkatesh Murthy.
A/Prof. & Head of Pathology
Percent Change in Age-Adjusted Death Rates,
4th leading cause of death, women more, smoking >80%
Proportion of 1965 Rate
Stroke Other CVD COPD All Other
–59% –64% –35% +163% –7%
1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998
Pathology of Smoking
Research evidence: smoking disease
>4000 chemicals, 43 carcinogens.
>90% of COPD is due to smoking.
15% of smokers develop COPD.
Injury & inflammation central to damage.
Smoking a single cigarette results in an acute
increase in neutrophils at 1 hour.
Increased neutrophils in smokers, which
decrease following reduction/quitting.
Patients with COPD have sputum neutrophilia
that persists even after cessation of smoking.
Pneumonia: Clinical vignette
50y man, alcoholic, high fever, cough, copious foul
smelling brown sputum, pleuritic rt sided chest pain.
HPC: wife reports that he was brought home in a semi-conscious
state a few days ago – drunk.
Thin, distressed, pursed lip breathing, using accessory
muscles of respiration, cannot speak in full sentences,
39°C, RR-22/min, peripheral cyanosis.
Chest-rib in-drawing, diminished air entry, soft expiratory
wheezes, bronchial breathing L lower post chest.
PE: fever, consolidation right middle and lower lobes.
sputum microscopy - abundant PMN and mixed oral
Pathogenesis, Differential diagnosis…..?
What is pneumonia? Types? pathogenesis?
Lobar, Broncho & Interstial pneumonia?
Community acquired / Nosocomial / hospital acquired
pneumonia ? What is the difference ?
Acute, Chronic & recurrent pneumonia?
Typical, Atypical pneumonia?
Common organisms causing pneumonia?
Microbiology – lab diagnosis, culture, tests.
Gross and microscopy of pneumonia.
Phases of pneumonia – Congestion, Red hepatization, Grey
Complications of pneumonia?
Lipoid pneumonia, Carcinomatous & Aspiration pneumonia ?
Restrictive vs Obstructive
Interstitial - (stiff lung)
Acute – ARDS,Viral.
sarcoidosis, Int. fibrosis.
Obstructive (soft lung)
Destruction of tissue.
Low FEV1:VC ratio
•Localised & Diffuse
•Reversible & progressive.
Pulmonary Function Testing:
FVC - Forced Vital Capacity – Liters - diagnosis of obstructive and
FEV1 - Forced Expiratory Volume in One Second –
FEV1/FVC - FEV1 Percent (FEV1%) - it indicates what percentage
of the total FVC was expelled from the lungs during the first second
of forced exhalation. critically important in differentiating obstructive
from restrictive diseases.
FEV3 - Forced Expiratory Volume in Three Seconds – equal to FVC
FEV3/FVC - FEV3% - normal is 1 or 100%
PEFR - Peak Expiratory Flow Rate - this is maximum flow rate
achieved by the patient. For monitoring response to treatment.
FEF - Forced Expiratory Flow - is a measure of how much air can be
expired from the lungs (liters/second or liters/minute). The FVC
expiratory curve is divided into quartiles and therefore there is a FEF
that exists for each quartile. The quartiles are expressed as
FEF25%, FEF50%, and FEF75% of FVC.
Check FVC & FEV1 – normal normal PFT
If FVC and/or FEV1 are low - Pathology.
Check FEV1/FVC ratio:
FEV1/FVC% (<70%) - Obstructive.
FEV1 /FEVC% (>80%)- Restrictive.
An improvement in FEV1 of 200ml or more after
bronchodilator suggests versibility Asthma.
“A person with belief never grovels
before anyone, whining and whimpering
that it’s all too much, that he lacks
support, that he is being treated unfairly.
Instead, such a person tackles problems
head on and then affirms, I am greater
than anything that can happen to me.”
- Wings of Fire: An Autobiography of Dr. APJ Abdul Kalam.
Bronchial obstruction with overinflation
• Small areas of atelectasis (collapse) may be seen
Inflammation & thickening of mucosa.
Bronchial wall smooth muscle hypertrophy
Thickening of bronchial basement membrane.
Mucus plugging of bronchi
Curschmann spirals: whorls of shed epithelium
within mucus plugs
Charcot-Leyden crystals: Within aggregates of
eosinophils – crystalloids of galectin-10
Total Lung Capacity (TLC) - the total volume of the lung, the volume of
air contained in the lung at the end of maximal inspiration
Inspiratory Reserve Volume (IRV) - volume, which can be inspired
beyond a restful inspiration
Tidal Volume (TV) – volume of a single breath, usually at rest
Functional Residual Capacity (FRC) - The amount of air left in the lungs
after a tidal breath out, the amount of air that stays in the lungs during
Vital Capacity (VC) – maximum volume which can be ventilated in a
Inspiratory Capacity (IC) - the maximal volume that can be inspired
following a normal expiration
Expiratory Reserve Volume (ERV) – volume, which can be expired
beyond a restful expiration
Residual Volume (RV) – volume remaining in the lungs after a maximum
Forced Vital Capacity (FVC) - the volume of air
that can forcibly be blown out after full
inspiration, measured in litres
Forced Expiratory Volume in 1 Second (FEV1) -
the maximum volume of air that can forcibly
blow out in the first second during the FVC
manoeuvre, measured in liters
FEV1/FVC (FEV1%) - in healthy adults this
should be approximately 75–80%.
• Obstructive diseases (asthma, COPD) FEV1 is ↓ & FVC n/↑ so FEV1/FVC is
decreased (<80%, often ~45%).
• In restrictive diseases (Lung fibrosis/silicosis) FEV1 and FVC are both reduced
proportionally and the FEV1/FVC value may be normal or even increased as a
result of decreased lung compliance
Condition Major changes Causes Symptoms
Chronic Hyperplasia Tobacco smoking Productive
bronchitis and hypersecretion and air pollutants cough
of mucus glands
Bronchiectasis Dilation and scarring Persistent severe Cough, purulent
of airways infections sputum and fever
Asthma Smooth muscle Immunologic Episodic wheezing
hyperplasia or idiopathic cough and dyspnea
Emphysema Airspace enlargement Tobacco smoking Dyspnea
Genetic and wall destruction