Chronic Obstructive Pulmonary Disease

(COPD)
 Definition
 Etiology
 Pathogenesis
 Morphology
 Cor-pulmonale
 COPD

• Ventilatory disorder comprised of:

– Chronic bronchitis

– Emphysema

A smokers disease

Symptomatic patients usually have both

Chronic Bronchitis
Definition
Persistent cough with sputum production for at least 3
months in at least 2 consecutive years, in absence of
any other identifiable cause

Irreversible obstruction

Several forms

Simple chronic bronchitis: the productive cough with mucoid sputum, no

airflow obstruction
Chronic asthmatic bronchitis
Chronic obstructive bronchitis
 Etiology
• Cigarette smoke

• Air pollutants- sulfur dioxide, nitrogen dioxide

 Pathogenesis

Cigarette smoke

Chronic irritation Induce inflammation

(Neutrophils, macrophages,
lymphocytes, No
eosinophils)
Hypertrophy of mucous glands, ↑goblet cells

Proteases (elastase)
Hypersecretion of mucus Destruction, fibrosis

Mucus plug Stimulates mucus

Airways obstruction
hypersecretion
Infection- secondary role
 Pathogenesis

• Mucous hypersecretion- large bronchial

involvement

• Airways obstruction more peripheral

– Inflammation and fibrosis - narrowing of
bronchioles- small airways disease- chronic
bronchiolitis

– Coexistent emphysema
 Morphology

• Gross
– Mucosa edematous and red covered by mucus
material

• Microscopic
– Thickening of mucous secreting glands
– Increased goblet cells
– Peribronchial inflammation and fibrosis
– Increased Reid index ( normal 0.4)

Thickness of mucous glands

Reid index =
Thickness of bronchial wall
 Emphysema
Definition
Abnormal permanent enlargement of the airspaces distal
to the terminal bronchiole, accompanied by destruction of
their walls
 Types
• Classified according to anatomic distribution
within lobule
– Centriacinar- commonest
– Panacinar
– Distal acinar
– Irregular

• Only first two cause clinically significant airflow

obstruction
 Types

• Centriacinar emphysema
– Central or proximal parts of acini, i.e. respiratory
bronchioles are affected, distal alveoli are not
involved

– Occurs predominantly in heavy smokers, often in

association with chronic bronchitis
 Types

• Panacinar emphysema
– Acini uniformly enlarged from respiratory
bronchioles to alveoli

– Associated with alpha1 anti-trypsin deficiency

– Tends to occur more in lower zones of lung

Centriacinar emphysema Panacinar emphysema
 Types

Distal acinar
Distal acini involved, proximal normal

Commonly involved adjacent to pleura

Multiple enlarged air spaces forming cyst

like spaces- bulla- spontaneous
pneumothorax in young adults
 Types

• Irregular
– Acinus is irregularly involved

– Associated with scarring- healed inflammatory diseases

Etiopathogenesis

• Protease-antiprotease imbalance

• Oxidant-antioxidant imbalance
 Etiopathogenesis

Neutrophil elastase

Cigarette smoking- free

Cigarette smoking-
radicals
Inflammation- neutrophils,
macrophage
α1-antitrypsin deficiency
α1-antitrypsin

Protease-antiprotease imbalance
Etiopathogenesis

Free radicals (oxidant)

Cigarette smoking- Cigarette smoking-

Inflammation- Destruction of
neutrophils- antioxidant
in lungs

Superoxide
dismutase,Glutathione
(antioxidant)

Oxidant-antioxidant imbalance
Protease (elastase) Oxidant (free radicals)

Antioxidant
Antiprotease (α1-
(Superoxide
antitrypsin}
dismutase,
Glutathione)

Tissue Damage

Emphysema
 Morphology

• Gross
– Voluminous lungs, often overlapping the heart

– Apical bulla

– Large alveoli on cut section of the specimen

Normal lung gross Emphysema
 Morphology
• Microscopic
– Thinning and destruction of alveolar walls

– Abnormally large alveoli

– Loss of elastic tissue

• Reduced radial traction on the small
airways
• Tend to collapse during expiration
Normal lung: Micro

Emphysema
 Clinical Features
• Persistent cough with sputum (chronic bronchitis)

• Dyspnea, purse lip breathing (emphysema)

• Sever cases- hypercapnia, hypoxemia and

cyanosis(esp in chr bronchitis than emphysema)

• Barrel shaped chest (Emphysema)

• Cor-pulmonale (chronic bronchitis)

 Cor-pulmomale

• Chronic hypoxia

• Elevation of pulmonary vascular pressures

– Hypoxia induced vasoconstriction

• RV hypertrophy

• Right heart failure

– High JVP
– Hepatomegaly
– Pedal edema
 Difference between chronic bronchitis and
emphysema
• Chronic bronchitis- clinical definition

• Emphysema- morphologic definition

• Anatomic pattern distribution

– Chronic bronchitis- large and small airways involvement
– Emphysema- restricted to acinus (distal to terminal
bronchus)
Difference between chronic bronchitis and emphysema
Features Chronic bronchitis Emphysema
Age 40-50 50-75

Dyspnea Mild, late Severe, early

Cough Early, copious sputum Late, scanty sputum

Infections Common Occasional

Respiratory insufficiency Repeated Terminal

Corpulmonale Common Terminal

Elastic coil Normal Low

Chest X-Ray Large heart Hyperinflation, small heart

Appearance Blue Bloater Pink puffer

Thank You