Respiratory 05 – COPD

Definition: Types for Emphysema:

A disease state characterized by airflow limitation that is not fully
reversible.

Epidermiology: - in UK
- Only 10-20% of heavy smokers develop COPD
- Centri-acinar emphysematous spaces are found in the lungs of 50% of
British smokers over the age of 60 years
~ Smoking (>20cigarettes/day for >10years)
~ Fumes or smokes from biomass fuel
~ Poor ventilated air-polluted area
~ Occupation (coal miner or cadmium miner)
~ α1-antitripsin deficiency

Classification:

COPD
Pathology:
Emphysema Centriacinar (centrilobular) Panacinar
Chronic bronchitis
Aetiology Chronic smoking α1-antitripsin deficiency
Centriacinar paraseptal Micro Central or proximal part of acini Uniformly enlarged from
simple chronic
chronic asthmatic location (respi bronchioles) respiratory bronchioles to
bronchitis bronchitis panacinar irregular terminal blind alveoli
Location Common in upper lobe (apical) Common in lower lung zone
Morpho ~Deeper pink than in ~Well-developed, produce
(gross) panacinar emphysema & less pale, voluminous lung
voluminous

Aetiology:
~ Chronic bronchitis: productive cough for ≥3M for 2 consecutive yrs in the ~ Emphysematous changes
absence of identifiable cause. ~ Loss of the respiratory involve all the parts of acini
~ Emphysema: enlargement of air spaces & destruction of parenchyma, bronchioles in the proximal
causing closure of small airways & loss of lung elasticity portion of the acinus, with
sparing of distal alveoli.
Pathogenesis for emphysema: ~ Walls of emphysematous
Tobacco
spaces contain large
smoking amounts of black / brown
pigment
~ Inflammation around bronchi
Nicotine Free radical
and bronchioles is present
Morpho
activate ↑ oxidant level (micro)
inflam cells inactivation of
act as anti-protease
chemoattractant (functional α1- depletes
release IL-
for neutrophil antitripsin antioxidant level
8 & TNF
deficiency) in the lungs
more
neutrophil oxidant- ~ The enlarged air spaces ~ Air spaces of the entire
antioxidant acinus and lobule are
protease- imbalance around a small airway.
↑ neutrophil antiprotease ~ Respiratory epithelium enlarged, with only
elastase imbalance occasional remaining intact
tissue remains at the arrow.
damage ~ The more peripheral alveoli alveoli.
congenital ~ Inflammation and fibrosis are
α1-antitripsin are normal.
deficiency EMPHYSEMA minimally present.
 - Obesity
Paraseptal Irregular
(distal acinar)Chronic bronchitis Symptoms can be worsened by factors such as cold, foggy weather and
Aetiology
Aetiology Smoking
Spontaneous pneumothorax Associated with scarring atmospheric pollution.
Location Right or left
in young bronchus
adults (clinically insignificant)
Morpho
Micro Narrowing
Distal part arebronchus
or primarily with mucus
Acinusaccumulation
is irregularly involved Signs: ~ Wheezing
(gross)
location involved, adjacent to pleura ~ Tachypnea with prolonged expiration
& at margin of lobules ~ Use of accessory muscles during inspiration
Location Adjacent to areas of fibrosis, ~ ↓ chest expansion
scarring or atelectasis, upper ~ Hyperinflatted lung
half of the lung ~ Hyper-resonance percussion note
Morpho ~ Flapping tremor (hypercapnia)
(gross)
Emphysema: ~ pink puffers + barrel chest + pursed-lip breathing
Chronic bronchitis: ~ blue bloaters + late O2 retention
Morpho
(micro) Simple chronic bronchitis Chronic asthmatic bronchitis
Productive cough, no airway Intermittent bronchospasm
obstruct present

Terminal stage: ~ Heart failure

~ Oedema
~ Large dilated airspaces
~ that bulge inflam
↑ Chronic out fromcell in submucosa Investigation:
beneath the
~ Does not have pleura –bullae pathologic findings
characteristic Pulmonary Functional Test:
~Mild: FEV1 50-80% predicted
Morpho ~Moderate: FEV1 30-49% predicted
(micro) ~Severe: FEV1 <30% predicted
ABG: hypoxemia (V/Q mismatch), hypercapnia
FBC: polycythaemia (secondary to chronic hypoxemia)
CXR: flattened diaphragm, hyperinflation, bullae, ↑ lucency in the lung
CT scan: centrilobular emphysema, bullae
~ The loss of alveolar walls
Management / Treatment:
with emphysema is
~ Stop smoking-only way to slow down the progression
demonstrated.
~ Bronchodilator (β-agonist, anticholinergics, methylxanthines)
~ Remaining airspaces are
~ O2 supply: long-term or nighttime, depends on severity
dilated.
~ Antibiotics (for exacerbation case, not as prophylaxis)
~ Lung volume reduction surgery or lung transplant for end-stage

Sign & Symptoms:

Symptoms:
Chronic bronchitis Emphysema Complication:
~ Acute exacerbation  infection
- Cough with pulurent sputum - Minimal cough ~ Polycythaemia (high [RBC])
- Exertional dypsnea - Severe dypsnea ~ Respiratory failure (both type 1 & type 2)
- Fatigue - Weight loss ~ Cor pulmonale
- Wheezing ~ Lung carcinoma
Prognosis:
~ Stop smoking slows progression
~ Acute exacerbation (↑sxs, ↓lung f(x), ↑ sputum & fever, may due to
infection or response to antibiotics or any drug prescribed)

Pathogenesis for chronic bronchitis