acute bronchitis acute inflammation of the tracheobronchial tree, generally self-limited and with...

ACUTE BRONCHITISACUTE BRONCHITISACUTE BRONCHITISACUTE BRONCHITISAcute inflammation of the Acute inflammation of the

tracheobronchial tree, tracheobronchial tree, generally self-limited and with eventual generally self-limited and with eventual

complete healing and return of complete healing and return of function.function.

Though commonly mild, Though commonly mild, bronchitis may be serious in debilitated bronchitis may be serious in debilitated patients and those with chronic lung or patients and those with chronic lung or

heart disease.heart disease.Pneumonia is a critical complication.Pneumonia is a critical complication.

Acute inflammation of the Acute inflammation of the tracheobronchial tree, tracheobronchial tree,

generally self-limited and with eventual generally self-limited and with eventual complete healing and return of complete healing and return of

function.function.

Though commonly mild, Though commonly mild, bronchitis may be serious in debilitated bronchitis may be serious in debilitated patients and those with chronic lung or patients and those with chronic lung or

heart disease.heart disease.Pneumonia is a critical complication.Pneumonia is a critical complication.

Acute bronchitis:Acute bronchitis:

Acute infectious bronchitisAcute infectious bronchitis

Acute irritative bronchitisAcute irritative bronchitis

Cough-variant asthmaCough-variant asthma

Acute infectious bronchitisAcute infectious bronchitis


Cough-variant asthmaCough-variant asthma

Acute infectious bronchitisAcute infectious bronchitisAcute infectious bronchitisAcute infectious bronchitis

It may develop after a common cold or It may develop after a common cold or other viral infection of the nasopharynx, other viral infection of the nasopharynx, throat, or tracheobronchial tree, often throat, or tracheobronchial tree, often with secondary bacterial infection. with secondary bacterial infection.

Mycoplasma pneumoniae and Mycoplasma pneumoniae and Chlamydia also cause a. in. b., often in Chlamydia also cause a. in. b., often in young adults.young adults.

It may develop after a common cold or It may develop after a common cold or other viral infection of the nasopharynx, other viral infection of the nasopharynx, throat, or tracheobronchial tree, often throat, or tracheobronchial tree, often with secondary bacterial infection. with secondary bacterial infection.

Mycoplasma pneumoniae and Mycoplasma pneumoniae and Chlamydia also cause a. in. b., often in Chlamydia also cause a. in. b., often in young adults.young adults.

Acute infectious bronchitisAcute infectious bronchitisAcute infectious bronchitisAcute infectious bronchitis

Recurrent attacks often complicate chronic Recurrent attacks often complicate chronic bronchopulmonary diseases, which impair bronchopulmonary diseases, which impair bronchial clearance mechanisms. bronchial clearance mechanisms.

Repeated infections may be associated with:Repeated infections may be associated with: chronic sinusitischronic sinusitis

bronchiectasisbronchiectasis

bronchopulmonary alergybronchopulmonary alergy

in children – hypertrophied tonsils and adenoids. in children – hypertrophied tonsils and adenoids.

Recurrent attacks often complicate chronic Recurrent attacks often complicate chronic bronchopulmonary diseases, which impair bronchopulmonary diseases, which impair bronchial clearance mechanisms. bronchial clearance mechanisms.

Repeated infections may be associated with:Repeated infections may be associated with: chronic sinusitischronic sinusitis

bronchiectasisbronchiectasis

bronchopulmonary alergybronchopulmonary alergy

in children – hypertrophied tonsils and adenoids. in children – hypertrophied tonsils and adenoids.


May be caused by various mineral and May be caused by various mineral and vegetable dusts; fumes from strong vegetable dusts; fumes from strong acids, ammonia, certain volatile acids, ammonia, certain volatile organic solvents, chlorine, hydrogen organic solvents, chlorine, hydrogen sulfide, sulfur dioxide, or bromine; the sulfide, sulfur dioxide, or bromine; the environmental irritants ozone and environmental irritants ozone and nitrogen dioxide; or tobacco or other nitrogen dioxide; or tobacco or other smoke. smoke.

May be caused by various mineral and May be caused by various mineral and vegetable dusts; fumes from strong vegetable dusts; fumes from strong acids, ammonia, certain volatile acids, ammonia, certain volatile organic solvents, chlorine, hydrogen organic solvents, chlorine, hydrogen sulfide, sulfur dioxide, or bromine; the sulfide, sulfur dioxide, or bromine; the environmental irritants ozone and environmental irritants ozone and nitrogen dioxide; or tobacco or other nitrogen dioxide; or tobacco or other smoke. smoke.

Cought-variant asthmaCought-variant asthma

Asthma in which the degree of Asthma in which the degree of bronchoconstriction is not sufficient bronchoconstriction is not sufficient to produce overt wheezing.to produce overt wheezing.

It may be caused by allergen It may be caused by allergen inhalation, or chronic exposure to an inhalation, or chronic exposure to an airways irritant (airways airways irritant (airways hyperreactivity relatively mild)hyperreactivity relatively mild)

Asthma in which the degree of Asthma in which the degree of bronchoconstriction is not sufficient bronchoconstriction is not sufficient to produce overt wheezing.to produce overt wheezing.

It may be caused by allergen It may be caused by allergen inhalation, or chronic exposure to an inhalation, or chronic exposure to an airways irritant (airways airways irritant (airways hyperreactivity relatively mild)hyperreactivity relatively mild)

Acute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiologyAcute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiology

Hyperemia of the mucous membranesHyperemia of the mucous membranes

desquamation, edema leukocytic desquamation, edema leukocytic

infiltration of the submucosainfiltration of the submucosa

production of sticky or mucopurulent production of sticky or mucopurulent

exudateexudate

Hyperemia of the mucous membranesHyperemia of the mucous membranes

desquamation, edema leukocytic desquamation, edema leukocytic

infiltration of the submucosainfiltration of the submucosa

production of sticky or mucopurulent production of sticky or mucopurulent

exudateexudate


The protective functions of bronchial The protective functions of bronchial cilia, phagocytes, and lymphatics are cilia, phagocytes, and lymphatics are disturbeddisturbed

bacteria may invade the bronchibacteria may invade the bronchi

accumulation of cellular debris and accumulation of cellular debris and

mucopurulent exudatemucopurulent exudate

The protective functions of bronchial The protective functions of bronchial cilia, phagocytes, and lymphatics are cilia, phagocytes, and lymphatics are disturbeddisturbed

bacteria may invade the bronchibacteria may invade the bronchi

accumulation of cellular debris and accumulation of cellular debris and

mucopurulent exudatemucopurulent exudate


Cough, though distressing, is essential Cough, though distressing, is essential to eliminate bronchial secretionsto eliminate bronchial secretions

Cough, though distressing, is essential Cough, though distressing, is essential to eliminate bronchial secretionsto eliminate bronchial secretions

•edema of the bronchial walls•retained secretions•in same cases → spasm of bronchial muscules

•edema of the bronchial walls•retained secretions•in same cases → spasm of bronchial muscules

airways obstruction

airways obstruction

Acute bronchitis: Acute bronchitis: Symptoms and signsSymptoms and signsAcute bronchitis: Acute bronchitis: Symptoms and signsSymptoms and signs

Acute infectious bronchitis is often Acute infectious bronchitis is often preceded by symptoms of a URI:preceded by symptoms of a URI:

coryzacoryzamalaisemalaisechillinesschillinessslight feverslight feverback and muscle painback and muscle painsore throatsore throat

Acute infectious bronchitis is often Acute infectious bronchitis is often preceded by symptoms of a URI:preceded by symptoms of a URI:

coryzacoryzamalaisemalaisechillinesschillinessslight feverslight feverback and muscle painback and muscle painsore throatsore throat

Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs

Onset of cough usually signals onset of Onset of cough usually signals onset of bronchitis.bronchitis.

The cough is initially dry and nonproductiveThe cough is initially dry and nonproductive

small amounts of viscid sputum are raised after a small amounts of viscid sputum are raised after a

few hours or daysfew hours or days

it may later become more abundant and mucoid it may later become more abundant and mucoid

or mucopurulentor mucopurulent

Onset of cough usually signals onset of Onset of cough usually signals onset of bronchitis.bronchitis.

The cough is initially dry and nonproductiveThe cough is initially dry and nonproductive

small amounts of viscid sputum are raised after a small amounts of viscid sputum are raised after a

few hours or daysfew hours or days

it may later become more abundant and mucoid it may later become more abundant and mucoid

or mucopurulentor mucopurulent


Frankly purulent sputum Frankly purulent sputum

suggests superimposed suggests superimposed

bacterial infectionbacterial infection

Frankly purulent sputum Frankly purulent sputum

suggests superimposed suggests superimposed

bacterial infectionbacterial infection


In a severe uncomplicated case, In a severe uncomplicated case,

fever ~38,5fever ~38,5ºC may be present for ºC may be present for

up to 3 to 5 days, following up to 3 to 5 days, following

which acute symptoms subside.which acute symptoms subside.

In a severe uncomplicated case, In a severe uncomplicated case,

fever ~38,5fever ~38,5ºC may be present for ºC may be present for

up to 3 to 5 days, following up to 3 to 5 days, following

which acute symptoms subside.which acute symptoms subside.


Though cough may Though cough may

continue for several continue for several

weeksweeks..

Though cough may Though cough may

continue for several continue for several

weeksweeks..


Persistent fever Persistent fever

suggests suggests

complicating complicating

pneumoniapneumonia..

Persistent fever Persistent fever

suggests suggests

complicating complicating

pneumoniapneumonia..


Dyspnea may be Dyspnea may be

noted secondary to noted secondary to

the airways the airways

obstruction.obstruction.

Dyspnea may be Dyspnea may be

noted secondary to noted secondary to

the airways the airways

obstruction.obstruction.


Pulmonary signs are Pulmonary signs are

few in few in

uncomplicated uncomplicated

acute bronchitis.acute bronchitis.

Pulmonary signs are Pulmonary signs are

few in few in

uncomplicated uncomplicated

acute bronchitis.acute bronchitis.


scattered high- or low-pitched scattered high- or low-pitched

rhonchirhonchi

occasional cracklingoccasional crackling

oror

moist rales at the basesmoist rales at the bases

wheezing, especially after wheezing, especially after

cough.cough.

scattered high- or low-pitched scattered high- or low-pitched

rhonchirhonchi

occasional cracklingoccasional crackling

oror

moist rales at the basesmoist rales at the bases

wheezing, especially after wheezing, especially after

cough.cough.


Persistent localized Persistent localized

signs suggest signs suggest

development of development of

bronchopneumonia.bronchopneumonia.

Persistent localized Persistent localized

signs suggest signs suggest

development of development of

bronchopneumonia.bronchopneumonia.

Acute bronchitis:Acute bronchitis:diagnosisdiagnosis

Diagnosis is usually Diagnosis is usually based on the symptoms based on the symptoms and signsand signs

If the symptoms and signs If the symptoms and signs are serious or prolongedare serious or prolonged

chest x-raychest x-ray

Diagnosis is usually Diagnosis is usually based on the symptoms based on the symptoms and signsand signs

If the symptoms and signs If the symptoms and signs are serious or prolongedare serious or prolonged

chest x-raychest x-ray


Arterial blood gases Arterial blood gases

should be monitored should be monitored

when serious underlying when serious underlying

chronic respiratory chronic respiratory

disease is present.disease is present.

Arterial blood gases Arterial blood gases

should be monitored should be monitored

when serious underlying when serious underlying

chronic respiratory chronic respiratory

disease is present.disease is present.


In persons who do not In persons who do not

respond to antibiotic respond to antibiotic

therapy, or in special therapy, or in special

circumstances, Gram circumstances, Gram

stain and sputum culture stain and sputum culture

should be done to should be done to

determine the causative determine the causative

organism.organism.

In persons who do not In persons who do not

respond to antibiotic respond to antibiotic

therapy, or in special therapy, or in special

circumstances, Gram circumstances, Gram

stain and sputum culture stain and sputum culture

should be done to should be done to

determine the causative determine the causative

organism.organism.

CHRONIC AIRWAYS CHRONIC AIRWAYS OBSTRUCTIVE DISORDERSOBSTRUCTIVE DISORDERS

CHRONIC AIRWAYS CHRONIC AIRWAYS OBSTRUCTIVE DISORDERSOBSTRUCTIVE DISORDERS

CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE PULMONARY DISEASE = PULMONARY DISEASE = COPDCOPD

CHRONIC ASTHMATIC CHRONIC ASTHMATIC BRONCHITISBRONCHITIS

CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE PULMONARY DISEASE = PULMONARY DISEASE = COPDCOPD

CHRONIC ASTHMATIC CHRONIC ASTHMATIC BRONCHITISBRONCHITIS

CCOOPDPDCCOOPDPD

This chapter deals with generalized This chapter deals with generalized persistent airways obstruction persistent airways obstruction associated with varying associated with varying combinations of chronic combinations of chronic bronchitis, respiratory bronchiolitis bronchitis, respiratory bronchiolitis (small airways disease), asthma, (small airways disease), asthma, and emphysema.and emphysema.

This chapter deals with generalized This chapter deals with generalized persistent airways obstruction persistent airways obstruction associated with varying associated with varying combinations of chronic combinations of chronic bronchitis, respiratory bronchiolitis bronchitis, respiratory bronchiolitis (small airways disease), asthma, (small airways disease), asthma, and emphysema.and emphysema.

AIRWAYS OBSRUCTION AIRWAYS OBSRUCTION

increased increased resistance to resistance to airflow during airflow during

forced forced expirationexpiration

increased increased resistance to resistance to airflow during airflow during

forced forced expirationexpiration

Its hallmark is slowing of forced Its hallmark is slowing of forced expiration, producing characteristic expiration, producing characteristic

spirometric findings.spirometric findings.

It may result from narrowing or obliteration It may result from narrowing or obliteration of airways secondary to intrinsic airways of airways secondary to intrinsic airways

disease, from excessive expiratory disease, from excessive expiratory collapse of airways secondary to collapse of airways secondary to

pulmonary emphysema, from pulmonary emphysema, from „bronchospasm” (as in asthma), or from „bronchospasm” (as in asthma), or from

a combination of these factors. a combination of these factors.

Its hallmark is slowing of forced Its hallmark is slowing of forced expiration, producing characteristic expiration, producing characteristic

spirometric findings.spirometric findings.

It may result from narrowing or obliteration It may result from narrowing or obliteration of airways secondary to intrinsic airways of airways secondary to intrinsic airways

disease, from excessive expiratory disease, from excessive expiratory collapse of airways secondary to collapse of airways secondary to

pulmonary emphysema, from pulmonary emphysema, from „bronchospasm” (as in asthma), or from „bronchospasm” (as in asthma), or from

a combination of these factors. a combination of these factors.

Definitions of:Definitions of:

CHRONIC BRONCHITISCHRONIC BRONCHITIS CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE

BRONCHITISBRONCHITIS PULMONARY EMPHYSEMAPULMONARY EMPHYSEMA CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE

EMPHYSEMAEMPHYSEMA CHRONIC ASTHMATIC BRONCHITISCHRONIC ASTHMATIC BRONCHITIS

CHRONIC BRONCHITISCHRONIC BRONCHITIS CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE

BRONCHITISBRONCHITIS PULMONARY EMPHYSEMAPULMONARY EMPHYSEMA CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE

EMPHYSEMAEMPHYSEMA CHRONIC ASTHMATIC BRONCHITISCHRONIC ASTHMATIC BRONCHITIS

Chronic bronchitisChronic bronchitisChronic bronchitisChronic bronchitis

a condition associated with a condition associated with prolonged exposure to prolonged exposure to

nonspecific bronchial irritants nonspecific bronchial irritants and accompanied by mucus and accompanied by mucus hypersecretion and certain hypersecretion and certain

structural changes in the bronchistructural changes in the bronchi

a condition associated with a condition associated with prolonged exposure to prolonged exposure to

nonspecific bronchial irritants nonspecific bronchial irritants and accompanied by mucus and accompanied by mucus hypersecretion and certain hypersecretion and certain

structural changes in the bronchistructural changes in the bronchi

Chronic obstructive Chronic obstructive bronchitisbronchitis

disease of the small airways of disease of the small airways of

sufficient degree to lead to sufficient degree to lead to

clinically significant airways clinically significant airways

obstructionobstruction

disease of the small airways of disease of the small airways of

sufficient degree to lead to sufficient degree to lead to

clinically significant airways clinically significant airways


Pulmonary emphysemaPulmonary emphysema

enlargement of the airspaces distal enlargement of the airspaces distal

to the terminal nonrespiratory to the terminal nonrespiratory

bronchioles, accompanied by bronchioles, accompanied by

destructive changes of the destructive changes of the

alveolar wallsalveolar walls

enlargement of the airspaces distal enlargement of the airspaces distal

to the terminal nonrespiratory to the terminal nonrespiratory

bronchioles, accompanied by bronchioles, accompanied by

destructive changes of the destructive changes of the

alveolar wallsalveolar walls

Chronic obstructive Chronic obstructive emphysemaemphysema

sufficient loss of lung recoil to sufficient loss of lung recoil to

allow marked airways collapse on allow marked airways collapse on

expiration, leading to the expiration, leading to the

physiologic pattern of airways physiologic pattern of airways


sufficient loss of lung recoil to sufficient loss of lung recoil to

allow marked airways collapse on allow marked airways collapse on

expiration, leading to the expiration, leading to the

physiologic pattern of airways physiologic pattern of airways


Chronic asthmatic Chronic asthmatic bronchitisbronchitis

An underlying asthmatic problem in An underlying asthmatic problem in

patients in whom the asthma has patients in whom the asthma has

become so persistent that clinically become so persistent that clinically

significant chronic airflow obstruction significant chronic airflow obstruction

is present despite antiasthmatic is present despite antiasthmatic

therapytherapy

An underlying asthmatic problem in An underlying asthmatic problem in

patients in whom the asthma has patients in whom the asthma has

become so persistent that clinically become so persistent that clinically

significant chronic airflow obstruction significant chronic airflow obstruction

is present despite antiasthmatic is present despite antiasthmatic

therapytherapy

These conditions These conditions frequently coexist frequently coexist and it may be difficult and it may be difficult in an individual case in an individual case to decide which is to decide which is the major one the major one producing the producing the obstruction.obstruction.

These conditions These conditions frequently coexist frequently coexist and it may be difficult and it may be difficult in an individual case in an individual case to decide which is to decide which is the major one the major one producing the producing the obstruction.obstruction.

This is particularly true This is particularly true

in regard to the in regard to the

combination of chronic combination of chronic

obstructive bronchitis obstructive bronchitis

and emphysema, which and emphysema, which

is often described with is often described with

the noncommittal term the noncommittal term

COPD.COPD.

This is particularly true This is particularly true

in regard to the in regard to the

combination of chronic combination of chronic

obstructive bronchitis obstructive bronchitis

and emphysema, which and emphysema, which

is often described with is often described with

the noncommittal term the noncommittal term

COPD.COPD.

Interrelationship of Interrelationship of asthma, small airways asthma, small airways disease, and persistent disease, and persistent

airways obstructionairways obstruction..

Interrelationship of Interrelationship of asthma, small airways asthma, small airways disease, and persistent disease, and persistent

airways obstructionairways obstruction..

Shaded areas represent patients with clinically significant chronic airways obstruction.

APatients with a relatively pure emphysematous-type disease

B patients with a pure type of chronic obstructive bronchitis

C patients with typical asthma, which is so persistent that there is clinically significant chronic airflow limitation

D patients with chronic asthmatic bronchitis who may show considerable fluctuation in the severity of the airways obstruction but never return to normal

X patients with a totally mixed type of disease.

Shaded areas represent patients with clinically significant chronic airways obstruction.

APatients with a relatively pure emphysematous-type disease

B patients with a pure type of chronic obstructive bronchitis

C patients with typical asthma, which is so persistent that there is clinically significant chronic airflow limitation

D patients with chronic asthmatic bronchitis who may show considerable fluctuation in the severity of the airways obstruction but never return to normal

X patients with a totally mixed type of disease.

DEFINITION OF COPDDEFINITION OF COPDA CHRONIC, SLOWLY PROGRESSIVE A CHRONIC, SLOWLY PROGRESSIVE

DISORDER CHARACTERISED BY AIRFLOW DISORDER CHARACTERISED BY AIRFLOW OBSTRUCTION OBSTRUCTION

(FEV(FEV11<80% PREDICTED AND FEV<80% PREDICTED AND FEV11/VC /VC

RATIO<70%)RATIO<70%)

WHICH DOES NOT CHANGE MARKEDLY OVER WHICH DOES NOT CHANGE MARKEDLY OVER SEVERAL MONTHS.SEVERAL MONTHS.

The impairment of lung function is largely fixed The impairment of lung function is largely fixed but may be partially responsible by but may be partially responsible by

bronchodilator therapy.bronchodilator therapy.

A CHRONIC, SLOWLY PROGRESSIVE A CHRONIC, SLOWLY PROGRESSIVE DISORDER CHARACTERISED BY AIRFLOW DISORDER CHARACTERISED BY AIRFLOW

OBSTRUCTION OBSTRUCTION

(FEV(FEV11<80% PREDICTED AND FEV<80% PREDICTED AND FEV11/VC /VC

RATIO<70%)RATIO<70%)

WHICH DOES NOT CHANGE MARKEDLY OVER WHICH DOES NOT CHANGE MARKEDLY OVER SEVERAL MONTHS.SEVERAL MONTHS.

The impairment of lung function is largely fixed The impairment of lung function is largely fixed but may be partially responsible by but may be partially responsible by

bronchodilator therapy.bronchodilator therapy.

DEFINITION OF COPDDEFINITION OF COPD

Historically, the term „chronic Historically, the term „chronic

bronchitis” was used to define any bronchitis” was used to define any

patient who coughed up sputum on patient who coughed up sputum on

most days of at least 3 consecutive most days of at least 3 consecutive

months for more than 2 successive months for more than 2 successive

years (provided other causes of years (provided other causes of

coughhad been excluded).coughhad been excluded).

Historically, the term „chronic Historically, the term „chronic

bronchitis” was used to define any bronchitis” was used to define any

patient who coughed up sputum on patient who coughed up sputum on

most days of at least 3 consecutive most days of at least 3 consecutive

months for more than 2 successive months for more than 2 successive

years (provided other causes of years (provided other causes of

coughhad been excluded).coughhad been excluded).

DEFINITION OF COPDDEFINITION OF COPD

The term „emphysema” referred to the The term „emphysema” referred to the

pathological process of a permanent pathological process of a permanent

destructive enlargement of the destructive enlargement of the

airspaces distal to the terminal airspaces distal to the terminal

bronchioles. bronchioles.

The term „emphysema” referred to the The term „emphysema” referred to the

pathological process of a permanent pathological process of a permanent

destructive enlargement of the destructive enlargement of the

airspaces distal to the terminal airspaces distal to the terminal

bronchioles. bronchioles.

The death rate from COPD The death rate from COPD

currently exceeds currently exceeds

25 000/year 25 000/year

in United Kingdomin United Kingdom

(>10-fold higher than (>10-fold higher than

asthma)asthma)

The death rate from COPD The death rate from COPD

currently exceeds currently exceeds

25 000/year 25 000/year

in United Kingdomin United Kingdom

(>10-fold higher than (>10-fold higher than

asthma)asthma)

The basic lesion of emphysema is The basic lesion of emphysema is believed to result from the effect on believed to result from the effect on

the alveolar wall of proteolytic the alveolar wall of proteolytic enzymes, which can be released enzymes, which can be released

from leucocytes participating in an from leucocytes participating in an inflammatory process. inflammatory process.

Thus, any factor leading to chronic Thus, any factor leading to chronic alveolar inflammation would alveolar inflammation would

encourage development of an encourage development of an emphysematous lesion unless emphysematous lesion unless

counteracted by the body’s counteracted by the body’s antiproteolytic mechanisms. antiproteolytic mechanisms.

The basic lesion of emphysema is The basic lesion of emphysema is believed to result from the effect on believed to result from the effect on

the alveolar wall of proteolytic the alveolar wall of proteolytic enzymes, which can be released enzymes, which can be released

from leucocytes participating in an from leucocytes participating in an inflammatory process. inflammatory process.

Thus, any factor leading to chronic Thus, any factor leading to chronic alveolar inflammation would alveolar inflammation would

encourage development of an encourage development of an emphysematous lesion unless emphysematous lesion unless

counteracted by the body’s counteracted by the body’s antiproteolytic mechanisms. antiproteolytic mechanisms.

The single most important cause of The single most important cause of COPD is cigarette smoking and a COPD is cigarette smoking and a

direct correlation exists between the direct correlation exists between the number of cigarettes smoked in pack number of cigarettes smoked in pack

yearsyears

(1 pack year = 20 cigarettes smoked (1 pack year = 20 cigarettes smoked daily for a year)daily for a year)

and the likelihood of developing the and the likelihood of developing the disease. disease.

The single most important cause of The single most important cause of COPD is cigarette smoking and a COPD is cigarette smoking and a

direct correlation exists between the direct correlation exists between the number of cigarettes smoked in pack number of cigarettes smoked in pack

yearsyears

(1 pack year = 20 cigarettes smoked (1 pack year = 20 cigarettes smoked daily for a year)daily for a year)

and the likelihood of developing the and the likelihood of developing the disease. disease.

Model of annual decline in FEV1 with accelerated Model of annual decline in FEV1 with accelerated decline in susceptible smokers.decline in susceptible smokers.

Model of annual decline in FEV1 with accelerated Model of annual decline in FEV1 with accelerated decline in susceptible smokers.decline in susceptible smokers.

On stopping smoking, subsequent loss is similar to that in On stopping smoking, subsequent loss is similar to that in healthy non-smokers.healthy non-smokers.

On stopping smoking, subsequent loss is similar to that in On stopping smoking, subsequent loss is similar to that in healthy non-smokers.healthy non-smokers.

Smoking is thought to have its Smoking is thought to have its effect by inducing persisting effect by inducing persisting airway inflammation and airway inflammation and causing a direct imbalance in causing a direct imbalance in oxidant/antioxidant capacity and oxidant/antioxidant capacity and proteinase/antiproteinase load proteinase/antiproteinase load in the lungs. in the lungs.

Individual susceptibility to Individual susceptibility to smoking is very widesmoking is very wide

only ~15% smokers develoonly ~15% smokers developp clinically significant COPDclinically significant COPD

Smoking is thought to have its Smoking is thought to have its effect by inducing persisting effect by inducing persisting airway inflammation and airway inflammation and causing a direct imbalance in causing a direct imbalance in oxidant/antioxidant capacity and oxidant/antioxidant capacity and proteinase/antiproteinase load proteinase/antiproteinase load in the lungs. in the lungs.

Individual susceptibility to Individual susceptibility to smoking is very widesmoking is very wide

only ~15% smokers develoonly ~15% smokers developp clinically significant COPDclinically significant COPD

Homozygotic Homozygotic αα11--antitrypsin deficiencyantitrypsin deficiency

In In this rare congenital condition this rare congenital condition a a persons’s ability to neutralize persons’s ability to neutralize proteases is markedly diminishedproteases is markedly diminished

eemphysema may develop by middle age mphysema may develop by middle age even without exposure to substances even without exposure to substances

that interfere with lung defenses. that interfere with lung defenses.

In In this rare congenital condition this rare congenital condition a a persons’s ability to neutralize persons’s ability to neutralize proteases is markedly diminishedproteases is markedly diminished

eemphysema may develop by middle age mphysema may develop by middle age even without exposure to substances even without exposure to substances

that interfere with lung defenses. that interfere with lung defenses.

A small additional contribution to the A small additional contribution to the severity of COPD has been reported in severity of COPD has been reported in patients exposed to dusty or air-polluted patients exposed to dusty or air-polluted environments.environments.

Association between development of Association between development of COPD and:COPD and: low birth weightlow birth weight bronchial hyper-responsiveness bronchial hyper-responsiveness

A small additional contribution to the A small additional contribution to the severity of COPD has been reported in severity of COPD has been reported in patients exposed to dusty or air-polluted patients exposed to dusty or air-polluted environments.environments.

Association between development of Association between development of COPD and:COPD and: low birth weightlow birth weight bronchial hyper-responsiveness bronchial hyper-responsiveness

COPD: pathologyCOPD: pathology

Most patients develop:Most patients develop:airway wall inflammationairway wall inflammationhypertrophy of the mucus-secreting hypertrophy of the mucus-secreting

glandsglandsincrease in the number of goblet increase in the number of goblet

cells in the bronchi and bronchiolescells in the bronchi and bronchiolesdecrease in the number of ciliated decrease in the number of ciliated

cellscells

Most patients develop:Most patients develop:airway wall inflammationairway wall inflammationhypertrophy of the mucus-secreting hypertrophy of the mucus-secreting

glandsglandsincrease in the number of goblet increase in the number of goblet

cells in the bronchi and bronchiolescells in the bronchi and bronchiolesdecrease in the number of ciliated decrease in the number of ciliated

cellscells


Airflow limitation reflects both Airflow limitation reflects both mechanical obstruction in the small mechanical obstruction in the small airways and loss of pulmonary elastic airways and loss of pulmonary elastic recoil.recoil.

Loss of alveolar attachments around Loss of alveolar attachments around such airways makes them more liable such airways makes them more liable to collapse during expiration. to collapse during expiration.

Airflow limitation reflects both Airflow limitation reflects both mechanical obstruction in the small mechanical obstruction in the small airways and loss of pulmonary elastic airways and loss of pulmonary elastic recoil.recoil.

Loss of alveolar attachments around Loss of alveolar attachments around such airways makes them more liable such airways makes them more liable to collapse during expiration. to collapse during expiration.


Emphysema is usually centriacinar, Emphysema is usually centriacinar, involving respiratory bronchioles, involving respiratory bronchioles, alveolar ducts and centrally located alveolar ducts and centrally located alveoli.alveoli.

More rarely, panacinar emphysema or More rarely, panacinar emphysema or paraseptal emphysema develops, with paraseptal emphysema develops, with the latter responsible for blebs on the the latter responsible for blebs on the lung surface and/or giant bullae. lung surface and/or giant bullae.

Emphysema is usually centriacinar, Emphysema is usually centriacinar, involving respiratory bronchioles, involving respiratory bronchioles, alveolar ducts and centrally located alveolar ducts and centrally located alveoli.alveoli.

More rarely, panacinar emphysema or More rarely, panacinar emphysema or paraseptal emphysema develops, with paraseptal emphysema develops, with the latter responsible for blebs on the the latter responsible for blebs on the lung surface and/or giant bullae. lung surface and/or giant bullae.


Pulmonary vascular remodellingPulmonary vascular remodelling

persistent hypoxaemiapersistent hypoxaemia

pulmonary hypertensions pulmonary hypertensions and and

right ventricular hypertrophy right ventricular hypertrophy and dilatationand dilatation

Pulmonary vascular remodellingPulmonary vascular remodelling

persistent hypoxaemiapersistent hypoxaemia

pulmonary hypertensions pulmonary hypertensions and and

right ventricular hypertrophy right ventricular hypertrophy and dilatationand dilatation

Cor pulmonale

Cor pulmonale

The pathology of The pathology of emphysemaemphysemaThe pathology of The pathology of emphysemaemphysema

Normal lungNormal lung

Emphysematous Emphysematous lung showing gross lung showing gross loss of the normal loss of the normal surface area available surface area available for gas exchangefor gas exchange

Normal lungNormal lung

Emphysematous Emphysematous lung showing gross lung showing gross loss of the normal loss of the normal surface area available surface area available for gas exchangefor gas exchange

COPD: symptoms and COPD: symptoms and signssigns

COPD is thought to COPD is thought to begin early in adult begin early in adult

life, though life, though significant significant

symptoms and symptoms and disability usually do disability usually do

not occur until not occur until middle age. middle age.

COPD is thought to COPD is thought to begin early in adult begin early in adult

life, though life, though significant significant

symptoms and symptoms and disability usually do disability usually do

not occur until not occur until middle age. middle age.

Mild ventilatory Mild ventilatory abnormalities abnormalities may be may be discernible long discernible long before the onset before the onset of significant of significant clinical clinical symptoms.symptoms.

Mild ventilatory Mild ventilatory abnormalities abnormalities may be may be discernible long discernible long before the onset before the onset of significant of significant clinical clinical symptoms.symptoms.


Mild „smoker’s Mild „smoker’s cough” is often cough” is often present many present many years before years before onset of onset of exertional exertional dyspnea.dyspnea.

Mild „smoker’s Mild „smoker’s cough” is often cough” is often present many present many years before years before onset of onset of exertional exertional dyspnea.dyspnea.


spirometric

screening

of smokers

spirometric

screening

of smokers? !? !

Classification of COPDClassification of COPD

Severity: Severity:

mildmild

moderatemoderate

severe severe


MildMild

Spirometry:Spirometry: FEV1 60-79% predicted FEV1 60-79% predicted

Symptoms:Symptoms: smoker’s cough smoker’s cough ±±

exertional breathlessnessexertional breathlessness

MildMild

Spirometry:Spirometry: FEV1 60-79% predicted FEV1 60-79% predicted

Symptoms:Symptoms: smoker’s cough smoker’s cough ±±

exertional breathlessnessexertional breathlessness


Moderate Moderate

Spirometry:Spirometry: FEV1 40 - 59% predicted FEV1 40 - 59% predicted

Symptoms:Symptoms: exertional breathlessnessexertional breathlessness

± wheeze; ± wheeze;

cough ± sputumcough ± sputum

Moderate Moderate

Spirometry:Spirometry: FEV1 40 - 59% predicted FEV1 40 - 59% predicted

Symptoms:Symptoms: exertional breathlessnessexertional breathlessness

± wheeze; ± wheeze;

cough ± sputumcough ± sputum


SevereSevere

Spirometry:Spirometry: FEV1 <40% predicted FEV1 <40% predicted

Symptoms:Symptoms: breathlessnessbreathlessness,, wheeze wheeze

and and

cough prominent; swollen legscough prominent; swollen legs

SevereSevere

Spirometry:Spirometry: FEV1 <40% predicted FEV1 <40% predicted

Symptoms:Symptoms: breathlessnessbreathlessness,, wheeze wheeze

and and

cough prominent; swollen legscough prominent; swollen legs

The disease generally starts with The disease generally starts with

repeated attacks of productive repeated attacks of productive

cough, usually after colds during cough, usually after colds during

the winter months, which show a the winter months, which show a

steady increase in severity and steady increase in severity and

duration with successive years duration with successive years

until cough is present all the year until cough is present all the year

round.round.

The disease generally starts with The disease generally starts with

repeated attacks of productive repeated attacks of productive

cough, usually after colds during cough, usually after colds during

the winter months, which show a the winter months, which show a

steady increase in severity and steady increase in severity and

duration with successive years duration with successive years

until cough is present all the year until cough is present all the year

round.round.

Gradually progresGradually progresssive exertional ive exertional dyspnea is the most common dyspnea is the most common presenting complaint. presenting complaint.

Patients may date onset of dyspnea Patients may date onset of dyspnea to an acute respiratory illness; the to an acute respiratory illness; the acute infection may onlyacute infection may only unmask a unmask a preexisting subclinical chronic preexisting subclinical chronic respiratory disorder or it may reduce respiratory disorder or it may reduce an already limited respiratory an already limited respiratory reserve.reserve.

Gradually progresGradually progresssive exertional ive exertional dyspnea is the most common dyspnea is the most common presenting complaint. presenting complaint.

Patients may date onset of dyspnea Patients may date onset of dyspnea to an acute respiratory illness; the to an acute respiratory illness; the acute infection may onlyacute infection may only unmask a unmask a preexisting subclinical chronic preexisting subclinical chronic respiratory disorder or it may reduce respiratory disorder or it may reduce an already limited respiratory an already limited respiratory reserve.reserve.

WheezingWheezing

recurrent respiratory recurrent respiratory

infectionsinfections

occasionallyoccasionally

weaknessweakness

weight lossweight loss

lack of libido lack of libido

WheezingWheezing

recurrent respiratory recurrent respiratory

infectionsinfections


weaknessweakness

weight lossweight loss

lack of libido lack of libido

may also be

initial

manifestations

may also be

initial

manifestations

Rarely, initial complaints are Rarely, initial complaints are

related to heart failure related to heart failure

secondary to cor pulmonale, secondary to cor pulmonale,

because some patients because some patients

apparently ignore cough and apparently ignore cough and

dyspnea before the onset of dyspnea before the onset of

dependant edema and severe dependant edema and severe

cyanosis.cyanosis.

Rarely, initial complaints are Rarely, initial complaints are

related to heart failure related to heart failure

secondary to cor pulmonale, secondary to cor pulmonale,

because some patients because some patients

apparently ignore cough and apparently ignore cough and

dyspnea before the onset of dyspnea before the onset of

dependant edema and severe dependant edema and severe

cyanosis.cyanosis.

Cough and sputum production Cough and sputum production

are extremely variable.are extremely variable.

One patient may admit only to One patient may admit only to

„clearing my chest” on awakening in „clearing my chest” on awakening in

the mothe morrning or after smoking the first ning or after smoking the first

cigarette of the day. cigarette of the day.

Another may describe a severe Another may describe a severe

disabling cough.disabling cough.

Cough and sputum production Cough and sputum production

are extremely variable.are extremely variable.

One patient may admit only to One patient may admit only to

„clearing my chest” on awakening in „clearing my chest” on awakening in

the mothe morrning or after smoking the first ning or after smoking the first

cigarette of the day. cigarette of the day.

Another may describe a severe Another may describe a severe

disabling cough.disabling cough.

Sputum may be:Sputum may be: scantyscanty mucoidmucoid tenacioustenacious


streaked with blood during streaked with blood during infective exacerbationsinfective exacerbations

purulent during bacterial purulent during bacterial infectioninfection

scantyscanty mucoidmucoid tenacioustenacious


streaked with blood during streaked with blood during infective exacerbationsinfective exacerbations

purulent during bacterial purulent during bacterial infectioninfection

Breathlessness is Breathlessness is

aggravated by infection, aggravated by infection,

excessive cigarette excessive cigarette

smoking and adverse smoking and adverse

atmospheric conditions.atmospheric conditions.

Breathlessness is Breathlessness is

aggravated by infection, aggravated by infection,

excessive cigarette excessive cigarette

smoking and adverse smoking and adverse

atmospheric conditions.atmospheric conditions.

In patients with mild to moderate In patients with mild to moderate disease the respiratory disease the respiratory examination may be normal.examination may be normal.

However, variable numbers of However, variable numbers of inspiratory and expiratory inspiratory and expiratory rhonchi, mainly low- and rhonchi, mainly low- and medium-pitched, are audible in medium-pitched, are audible in most patients.most patients.

In patients with mild to moderate In patients with mild to moderate disease the respiratory disease the respiratory examination may be normal.examination may be normal.

However, variable numbers of However, variable numbers of inspiratory and expiratory inspiratory and expiratory rhonchi, mainly low- and rhonchi, mainly low- and medium-pitched, are audible in medium-pitched, are audible in most patients.most patients.

Crepitations which usually, Crepitations which usually,

but not always, disappear but not always, disappear

after coughing may be after coughing may be

audible over the lower zones. audible over the lower zones.

Crepitations which usually, Crepitations which usually,

but not always, disappear but not always, disappear

after coughing may be after coughing may be

audible over the lower zones. audible over the lower zones.

Clinical abnormalities in patients Clinical abnormalities in patients with advanced airflow obstructionwith advanced airflow obstructionClinical abnormalities in patients Clinical abnormalities in patients with advanced airflow obstructionwith advanced airflow obstruction

Rhonchi, especially on forced Rhonchi, especially on forced expirationexpiration

A reduction in the length of the A reduction in the length of the trachea palpable above the sternal trachea palpable above the sternal notchnotch

Tracheal descent during inspiration Tracheal descent during inspiration (tracheal „tug”)(tracheal „tug”)

Contraction of the sternomastoid and Contraction of the sternomastoid and scalene muscles on inspirationscalene muscles on inspiration

Rhonchi, especially on forced Rhonchi, especially on forced expirationexpiration

A reduction in the length of the A reduction in the length of the trachea palpable above the sternal trachea palpable above the sternal notchnotch

Tracheal descent during inspiration Tracheal descent during inspiration (tracheal „tug”)(tracheal „tug”)

Contraction of the sternomastoid and Contraction of the sternomastoid and scalene muscles on inspirationscalene muscles on inspiration


Excavation of the suprasternal and Excavation of the suprasternal and supraclavicular fossae during supraclavicular fossae during inspiration, together with indrawing of inspiration, together with indrawing of the costal margins and inthe costal margins and inttercostal ercostal spacesspaces

Increased antero-posterior diameter of Increased antero-posterior diameter of the chest relative to the lateral the chest relative to the lateral diameter; loss of cardiac dullnessdiameter; loss of cardiac dullness

Excavation of the suprasternal and Excavation of the suprasternal and supraclavicular fossae during supraclavicular fossae during inspiration, together with indrawing of inspiration, together with indrawing of the costal margins and inthe costal margins and inttercostal ercostal spacesspaces

Increased antero-posterior diameter of Increased antero-posterior diameter of the chest relative to the lateral the chest relative to the lateral diameter; loss of cardiac dullnessdiameter; loss of cardiac dullness


Loss of weight common (often Loss of weight common (often stimulates unnecessary investigation)stimulates unnecessary investigation)

Pursed-lip breathing – physiological Pursed-lip breathing – physiological response to decrease air trappingresponse to decrease air trapping

Central cyanosisCentral cyanosis Flapping tremor and bounding pulse Flapping tremor and bounding pulse

(due to hypercapnia)(due to hypercapnia)

Loss of weight common (often Loss of weight common (often stimulates unnecessary investigation)stimulates unnecessary investigation)

Pursed-lip breathing – physiological Pursed-lip breathing – physiological response to decrease air trappingresponse to decrease air trapping

Central cyanosisCentral cyanosis Flapping tremor and bounding pulse Flapping tremor and bounding pulse

(due to hypercapnia)(due to hypercapnia)


Peripheral oedema which may indicate Peripheral oedema which may indicate

cor pulmonalecor pulmonale

Raised JVP, right ventricular heave, Raised JVP, right ventricular heave,

loud pulmonary second sound, loud pulmonary second sound,

tricuspid regurgitationtricuspid regurgitation

Peripheral oedema which may indicate Peripheral oedema which may indicate

cor pulmonalecor pulmonale

Raised JVP, right ventricular heave, Raised JVP, right ventricular heave,

loud pulmonary second sound, loud pulmonary second sound,

tricuspid regurgitationtricuspid regurgitation

The diagnosis and The diagnosis and

classification of COPD classification of COPD

rests on objective rests on objective

demonstration of airways demonstration of airways

obstruction by obstruction by

spirometric testingspirometric testing

The diagnosis and The diagnosis and

classification of COPD classification of COPD

rests on objective rests on objective

demonstration of airways demonstration of airways

obstruction by obstruction by

spirometric testingspirometric testing

FEVFEV11 < 80% predicted < 80% predicted

FEVFEV11/VC ratio of <70%/VC ratio of <70%

little variation in serial PEFlittle variation in serial PEF

strongly suggests COPDstrongly suggests COPD

FEVFEV11 < 80% predicted < 80% predicted

FEVFEV11/VC ratio of <70%/VC ratio of <70%

little variation in serial PEFlittle variation in serial PEF

strongly suggests COPDstrongly suggests COPD

Reversibility testing to salbutamol Reversibility testing to salbutamol

and ipratropium bromide is and ipratropium bromide is

necessary to detect patients with necessary to detect patients with

substantial increases in FEV1 substantial increases in FEV1

who are really asthmatic, and to who are really asthmatic, and to

establish the post-term establish the post-term

prognosis.prognosis.

Reversibility testing to salbutamol Reversibility testing to salbutamol

and ipratropium bromide is and ipratropium bromide is

necessary to detect patients with necessary to detect patients with

substantial increases in FEV1 substantial increases in FEV1

who are really asthmatic, and to who are really asthmatic, and to

establish the post-term establish the post-term

prognosis.prognosis.

COPD cannot be diagnosed on a chest COPD cannot be diagnosed on a chest radiograph but this investigation is radiograph but this investigation is useful in excluding other pathology.useful in excluding other pathology.

In moderate and severe COPD the chest In moderate and severe COPD the chest radiograph typically shows radiograph typically shows

hypertranslucent lung fields with hypertranslucent lung fields with disorganisation of the vasculature, a disorganisation of the vasculature, a

low flat diaphragm or „terracing” of the low flat diaphragm or „terracing” of the hemidiaphragms and prominent hemidiaphragms and prominent

pulmonary artery shadows at both hila. pulmonary artery shadows at both hila.

Bulla may also be observed.Bulla may also be observed.

COPD cannot be diagnosed on a chest COPD cannot be diagnosed on a chest radiograph but this investigation is radiograph but this investigation is useful in excluding other pathology.useful in excluding other pathology.

In moderate and severe COPD the chest In moderate and severe COPD the chest radiograph typically shows radiograph typically shows

hypertranslucent lung fields with hypertranslucent lung fields with disorganisation of the vasculature, a disorganisation of the vasculature, a

low flat diaphragm or „terracing” of the low flat diaphragm or „terracing” of the hemidiaphragms and prominent hemidiaphragms and prominent

pulmonary artery shadows at both hila. pulmonary artery shadows at both hila.

Bulla may also be observed.Bulla may also be observed.

BRONCHIAL ASTHMABRONCHIAL ASTHMA

Chronic inflammatory Chronic inflammatory

disorder of the airways, disorder of the airways,

characterised by reversible characterised by reversible

airflow obstruction causing airflow obstruction causing

cough, wheeze, chest cough, wheeze, chest

tightness and shortness of tightness and shortness of

breath.breath.

Chronic inflammatory Chronic inflammatory

disorder of the airways, disorder of the airways,

characterised by reversible characterised by reversible

airflow obstruction causing airflow obstruction causing

cough, wheeze, chest cough, wheeze, chest

tightness and shortness of tightness and shortness of

breath.breath.


Inflammation of the bronchial wall Inflammation of the bronchial wall

involving eosinophils, mast cells involving eosinophils, mast cells

and lymphocytes, together with and lymphocytes, together with

the cytokine and inflammatory the cytokine and inflammatory

products of these cells, induces products of these cells, induces

hyper-responsiveness of the hyper-responsiveness of the

bronchi so that they narrow more bronchi so that they narrow more

readily in response to a wide readily in response to a wide

range of stimuli.range of stimuli.

Inflammation of the bronchial wall Inflammation of the bronchial wall

involving eosinophils, mast cells involving eosinophils, mast cells

and lymphocytes, together with and lymphocytes, together with

the cytokine and inflammatory the cytokine and inflammatory

products of these cells, induces products of these cells, induces

hyper-responsiveness of the hyper-responsiveness of the

bronchi so that they narrow more bronchi so that they narrow more

readily in response to a wide readily in response to a wide

range of stimuli.range of stimuli.


Narrowing of the airway is Narrowing of the airway is

usually reversible, but in some usually reversible, but in some

patients with chronic asthma patients with chronic asthma

the bronchial wall the bronchial wall

inflammation may lead to inflammation may lead to

irreversible obstruction of irreversible obstruction of

airflow.airflow.

Narrowing of the airway is Narrowing of the airway is

usually reversible, but in some usually reversible, but in some

patients with chronic asthma patients with chronic asthma

the bronchial wall the bronchial wall

inflammation may lead to inflammation may lead to

irreversible obstruction of irreversible obstruction of

airflow.airflow.


The airflow obstruction causes The airflow obstruction causes

mismatch of alveclar mismatch of alveclar

ventilation and perfusion and ventilation and perfusion and

increases the work of increases the work of

breathing.breathing.

Being more marked during Being more marked during

expiration it also causes air to expiration it also causes air to

be „trapped” in the lungs.be „trapped” in the lungs.

The airflow obstruction causes The airflow obstruction causes

mismatch of alveclar mismatch of alveclar

ventilation and perfusion and ventilation and perfusion and

increases the work of increases the work of

breathing.breathing.

Being more marked during Being more marked during

expiration it also causes air to expiration it also causes air to

be „trapped” in the lungs.be „trapped” in the lungs.


A narrowed bronchus can no A narrowed bronchus can no

longer be effectively cleared by longer be effectively cleared by

coughing up the mucus formed coughing up the mucus formed

by the disease process, and by the disease process, and

many of the bronchi become many of the bronchi become

obstructed by mucus plugs. obstructed by mucus plugs.

A narrowed bronchus can no A narrowed bronchus can no

longer be effectively cleared by longer be effectively cleared by

coughing up the mucus formed coughing up the mucus formed

by the disease process, and by the disease process, and

many of the bronchi become many of the bronchi become

obstructed by mucus plugs. obstructed by mucus plugs.

PatPathhological changes in asthmaological changes in asthma

Smooth muscle Smooth muscle hypertrophy and hypertrophy and hyperplasiahyperplasia

Smooth muscle Smooth muscle hypertrophy and hypertrophy and hyperplasiahyperplasia

Thickened basement Thickened basement membranemembraneThickened basement Thickened basement membranemembrane

Oedematous submucosa Oedematous submucosa with infiltration of with infiltration of granulocytesgranulocytes

Oedematous submucosa Oedematous submucosa with infiltration of with infiltration of granulocytesgranulocytes

Infiltration of bronchial Infiltration of bronchial and parabronchial and parabronchial tissues with monocytes tissues with monocytes and lymphocytesand lymphocytes

Infiltration of bronchial Infiltration of bronchial and parabronchial and parabronchial tissues with monocytes tissues with monocytes and lymphocytesand lymphocytes

Hyperplasia of Hyperplasia of mucous glandsmucous glandsHyperplasia of Hyperplasia of mucous glandsmucous glands

Desquamation of Desquamation of epitheliumepitheliumDesquamation of Desquamation of epitheliumepithelium

Mucus plugMucus plugMucus plugMucus plug

VasodilatationVasodilatationVasodilatationVasodilatation

BRONCHIAL ASTHMABRONCHIAL ASTHMA Bronchial asthma is a common Bronchial asthma is a common

disease.disease.

15% of children report an episode of 15% of children report an episode of

wheezing characteristic of asthma wheezing characteristic of asthma

within the previous yearwithin the previous year

5% have a diagnosis of asthma5% have a diagnosis of asthma

1% have severe disabling asthma1% have severe disabling asthma

2-5% adults have a clinical diagnosis 2-5% adults have a clinical diagnosis

of asthmaof asthma

Bronchial asthma is a common Bronchial asthma is a common

disease.disease.

15% of children report an episode of 15% of children report an episode of

wheezing characteristic of asthma wheezing characteristic of asthma

within the previous yearwithin the previous year

5% have a diagnosis of asthma5% have a diagnosis of asthma

1% have severe disabling asthma1% have severe disabling asthma

2-5% adults have a clinical diagnosis 2-5% adults have a clinical diagnosis

of asthmaof asthma

Long-term folLong-term folllow-up in ow-up in

developing countries developing countries

suggests that the suggests that the

disease may become disease may become

more frequent as more frequent as

individuals become more individuals become more

„Westernized”„Westernized”

Long-term folLong-term folllow-up in ow-up in

developing countries developing countries

suggests that the suggests that the

disease may become disease may become

more frequent as more frequent as

individuals become more individuals become more

„Westernized”„Westernized”

Bronchial asthma: Bronchial asthma: classificationclassification

Asthma cAsthma caan be dn be diivided into:vided into:

Extrinsic – implying a definite Extrinsic – implying a definite

external causeexternal cause

Intrinsic or cryptogenic – when no Intrinsic or cryptogenic – when no

causative agent can be identifiedcausative agent can be identified

Asthma cAsthma caan be dn be diivided into:vided into:

Extrinsic – implying a definite Extrinsic – implying a definite

external causeexternal cause

Intrinsic or cryptogenic – when no Intrinsic or cryptogenic – when no

causative agent can be identifiedcausative agent can be identified

Extrinsic asthmaExtrinsic asthma Occurs in atopic individuals who Occurs in atopic individuals who

show positive skin-prick reactions show positive skin-prick reactions to common inhaled allergens.to common inhaled allergens.

Positive skin tests to inhalant Positive skin tests to inhalant allergens are shown in 90% of allergens are shown in 90% of children with asthma, whereas children with asthma, whereas only 50% of adults show this only 50% of adults show this phenomenon.phenomenon.

Eczema is often seen in childhoodEczema is often seen in childhood

Occurs in atopic individuals who Occurs in atopic individuals who show positive skin-prick reactions show positive skin-prick reactions to common inhaled allergens.to common inhaled allergens.

Positive skin tests to inhalant Positive skin tests to inhalant allergens are shown in 90% of allergens are shown in 90% of children with asthma, whereas children with asthma, whereas only 50% of adults show this only 50% of adults show this phenomenon.phenomenon.

Eczema is often seen in childhoodEczema is often seen in childhood

Intrinsic asthmaIntrinsic asthma

Often starts in middle age. Often starts in middle age.

Nevertheless, many show Nevertheless, many show

positive skin tests and on close positive skin tests and on close

questioning give a history of questioning give a history of

respiratory symptoms compatible respiratory symptoms compatible

with childhood asthmawith childhood asthma

Often starts in middle age. Often starts in middle age.

Nevertheless, many show Nevertheless, many show

positive skin tests and on close positive skin tests and on close

questioning give a history of questioning give a history of

respiratory symptoms compatible respiratory symptoms compatible

with childhood asthmawith childhood asthma

This classification is of little value in This classification is of little value in clinical practice. Non-topic clinical practice. Non-topic individuals may develop asthma in individuals may develop asthma in middle age from extrinsic causes middle age from extrinsic causes such as sensitization to such as sensitization to occupational agents or aspirin occupational agents or aspirin intolerance, or because they were intolerance, or because they were given given β-adrenoreceptor-blocking β-adrenoreceptor-blocking agents for concurrent hypertension agents for concurrent hypertension or angina. or angina.

This classification is of little value in This classification is of little value in clinical practice. Non-topic clinical practice. Non-topic individuals may develop asthma in individuals may develop asthma in middle age from extrinsic causes middle age from extrinsic causes such as sensitization to such as sensitization to occupational agents or aspirin occupational agents or aspirin intolerance, or because they were intolerance, or because they were given given β-adrenoreceptor-blocking β-adrenoreceptor-blocking agents for concurrent hypertension agents for concurrent hypertension or angina. or angina.

Causes of asthma. Causes of asthma. Causes of asthma. Causes of asthma. AtopyAtopy

Allergy to inhalantsAllergy to inhalantsOccupational sensitisers

Isocyanates

Colophony fumes

Occupational sensitisers

Isocyanates

Colophony fumes

Atmospheric pollution

Sulphur dioxide

Ozone

Atmospheric pollution

Sulphur dioxide

Ozone

Drugs

β-Adrenoreceptor blocking agents

Drugs

β-Adrenoreceptor blocking agents

Viral infections

Rhinovirus

Parainfluenza virus

RSV

Viral infections

Rhinovirus

Parainfluenza virus

RSV

Cold airCold air

EmotionEmotion

Irritant dusts, vapor and fumes

Perfume

Cigarette smoke

Irritant dusts, vapor and fumes

Perfume

Cigarette smoke

Atopy and allergyAtopy and allergy The term „atopy” was used by clinicians The term „atopy” was used by clinicians

at the beginning of the centat the beginning of the centuury to ry to describe a group of disorders, including describe a group of disorders, including asthma and hay fever, that appeared:asthma and hay fever, that appeared:

To run in familiesTo run in families To have characteristic wealing skin reactions To have characteristic wealing skin reactions

to common allergens in the environmentto common allergens in the environment To have circulating antibody in their serum To have circulating antibody in their serum

that could be transferred to the skin of non-that could be transferred to the skin of non-sensitized individualssensitized individuals..

The term „atopy” was used by clinicians The term „atopy” was used by clinicians at the beginning of the centat the beginning of the centuury to ry to describe a group of disorders, including describe a group of disorders, including asthma and hay fever, that appeared:asthma and hay fever, that appeared:

To run in familiesTo run in families To have characteristic wealing skin reactions To have characteristic wealing skin reactions

to common allergens in the environmentto common allergens in the environment To have circulating antibody in their serum To have circulating antibody in their serum

that could be transferred to the skin of non-that could be transferred to the skin of non-sensitized individualssensitized individuals..

Atopy and allergyAtopy and allergy The term is now best used to The term is now best used to

describe those individuals who describe those individuals who readily develop antibodreadily develop antibodiies of IgE es of IgE class against common materials class against common materials present in the environmentpresent in the environment..

Genetic and environmental factors Genetic and environmental factors affect serum IgE levels affect serum IgE levels → early → early childhood exposure to allergens and childhood exposure to allergens and maternal smoking have an important maternal smoking have an important influence on IgE productioninfluence on IgE production..

The term is now best used to The term is now best used to describe those individuals who describe those individuals who readily develop antibodreadily develop antibodiies of IgE es of IgE class against common materials class against common materials present in the environmentpresent in the environment..

Genetic and environmental factors Genetic and environmental factors affect serum IgE levels affect serum IgE levels → early → early childhood exposure to allergens and childhood exposure to allergens and maternal smoking have an important maternal smoking have an important influence on IgE productioninfluence on IgE production..

Atopy and allergyAtopy and allergy

Allergens from the faecal Allergens from the faecal particles of the house-dust particles of the house-dust mite are the most important mite are the most important extrinsic cause of asthma extrinsic cause of asthma worworlldwide.dwide.

The fungal spores from The fungal spores from A. A. fumigatusfumigatus give rise to a give rise to a complex series of lung complex series of lung disease, including asthma.disease, including asthma.

Allergens from the faecal Allergens from the faecal particles of the house-dust particles of the house-dust mite are the most important mite are the most important extrinsic cause of asthma extrinsic cause of asthma worworlldwide.dwide.

The fungal spores from The fungal spores from A. A. fumigatusfumigatus give rise to a give rise to a complex series of lung complex series of lung disease, including asthma.disease, including asthma.

Increased responsiveness of Increased responsiveness of the airways of the lung (airway the airways of the lung (airway hyperreactivity)hyperreactivity)


Bronchial reactivity can by Bronchial reactivity can by

demonstrated by asking the patient to demonstrated by asking the patient to

inhale gradually increasing inhale gradually increasing

concentrations of histamine or concentrations of histamine or

methacholine methacholine (bronchial provocation (bronchial provocation

tests).tests).

Bronchial reactivity can by Bronchial reactivity can by

demonstrated by asking the patient to demonstrated by asking the patient to

inhale gradually increasing inhale gradually increasing

concentrations of histamine or concentrations of histamine or

methacholine methacholine (bronchial provocation (bronchial provocation

tests).tests).



Patients with clinical symptoms of Patients with clinical symptoms of

asthma respond to very low doses of asthma respond to very low doses of

methacholine (PDmethacholine (PD2020FEVFEV11<11<11μmol)μmol)..

PDPD2020FEVFEV11 → → the dose of the agonist the dose of the agonist

(provocation dose) necessary to (provocation dose) necessary to

produce a 20% fall in FEVproduce a 20% fall in FEV11

Patients with clinical symptoms of Patients with clinical symptoms of

asthma respond to very low doses of asthma respond to very low doses of

methacholine (PDmethacholine (PD2020FEVFEV11<11<11μmol)μmol)..

PDPD2020FEVFEV11 → → the dose of the agonist the dose of the agonist

(provocation dose) necessary to (provocation dose) necessary to

produce a 20% fall in FEVproduce a 20% fall in FEV11

Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures

Patients suffering from asthma Patients suffering from asthma

exhibit virtually identical exhibit virtually identical

symptoms to those suffering symptoms to those suffering

from airflow limitation caused by from airflow limitation caused by

chronic bronchitis and chronic bronchitis and

emphysema.emphysema.

Patients suffering from asthma Patients suffering from asthma

exhibit virtually identical exhibit virtually identical

symptoms to those suffering symptoms to those suffering

from airflow limitation caused by from airflow limitation caused by

chronic bronchitis and chronic bronchitis and

emphysema.emphysema.


The symptoms of asthma The symptoms of asthma

consist of a triad of dyspnea, consist of a triad of dyspnea,

cough, and wcough, and whheezing.eezing.

In its most typical form asthma In its most typical form asthma

is an episodic disease, and all is an episodic disease, and all

three symptoms coexist. three symptoms coexist.

The symptoms of asthma The symptoms of asthma

consist of a triad of dyspnea, consist of a triad of dyspnea,

cough, and wcough, and whheezing.eezing.

In its most typical form asthma In its most typical form asthma

is an episodic disease, and all is an episodic disease, and all

three symptoms coexist. three symptoms coexist.


Bronchial asthma may be either Bronchial asthma may be either

episodic or chronic.episodic or chronic.

In episodic asthma the patient In episodic asthma the patient

has no respiratory symptoms or has no respiratory symptoms or

signs between episodes signs between episodes

(attacks) of asthma .(attacks) of asthma .

Bronchial asthma may be either Bronchial asthma may be either

episodic or chronic.episodic or chronic.

In episodic asthma the patient In episodic asthma the patient

has no respiratory symptoms or has no respiratory symptoms or

signs between episodes signs between episodes

(attacks) of asthma .(attacks) of asthma .


Attacks:Attacks: often occur at night, often occur at night,

may also abruptly follow exposure to may also abruptly follow exposure to

a specific allergen, physical exertion, a specific allergen, physical exertion,

a viral respiratory infection, or a viral respiratory infection, or

emotional excitement. emotional excitement.

Attacks:Attacks: often occur at night, often occur at night,

may also abruptly follow exposure to may also abruptly follow exposure to

a specific allergen, physical exertion, a specific allergen, physical exertion,

a viral respiratory infection, or a viral respiratory infection, or

emotional excitement. emotional excitement.


Attacks:Attacks:

at the onset the patient experiat the onset the patient experieences nces

a sense of constriction in the chest, a sense of constriction in the chest,

often with a nonproductive cough.often with a nonproductive cough.

Attacks:Attacks:

at the onset the patient experiat the onset the patient experieences nces

a sense of constriction in the chest, a sense of constriction in the chest,

often with a nonproductive cough.often with a nonproductive cough.


RRespiration becomes audibly harsh, espiration becomes audibly harsh,

and wand whheezing in both phases of eezing in both phases of

respiration becomes prominent, respiration becomes prominent,

expiration becomes prolongedexpiration becomes prolonged

Patients frequently have tachypnoe, Patients frequently have tachypnoe,

tachycardia, and mild systolic tachycardia, and mild systolic

hypertension.hypertension.

RRespiration becomes audibly harsh, espiration becomes audibly harsh,

and wand whheezing in both phases of eezing in both phases of

respiration becomes prominent, respiration becomes prominent,

expiration becomes prolongedexpiration becomes prolonged

Patients frequently have tachypnoe, Patients frequently have tachypnoe,

tachycardia, and mild systolic tachycardia, and mild systolic

hypertension.hypertension.


TThe lungs rapidly become he lungs rapidly become

overinflated, and the anterior-overinflated, and the anterior-

posterior diameter of the thorax posterior diameter of the thorax

increased.increased.

TThe lungs rapidly become he lungs rapidly become

overinflated, and the anterior-overinflated, and the anterior-

posterior diameter of the thorax posterior diameter of the thorax

increased.increased.


If the attack is severe or If the attack is severe or

prolonged, the accessory prolonged, the accessory

become visibly active and become visibly active and

frequently a paradoxical pulse frequently a paradoxical pulse

will develop.will develop.

If the attack is severe or If the attack is severe or

prolonged, the accessory prolonged, the accessory

become visibly active and become visibly active and

frequently a paradoxical pulse frequently a paradoxical pulse

will develop.will develop.


Severe acute asthma Severe acute asthma

„status asthmaticus”„status asthmaticus”

Life-threatening attacks of Life-threatening attacks of

asthma.asthma.

Severe acute asthma Severe acute asthma

„status asthmaticus”„status asthmaticus”

Life-threatening attacks of Life-threatening attacks of

asthma.asthma.

Chronic asthmaChronic asthma Symptoms:Symptoms:

chest tightness, chest tightness, wheezewheezebreathlessness on exertion, breathlessness on exertion, spontaneous cough and whespontaneous cough and wheeeze during ze during

the night and early morningthe night and early morningrecurrent episodes of frank respiratory recurrent episodes of frank respiratory

infectioninfectionepisodes of severe acute asthmaepisodes of severe acute asthma

Symptoms:Symptoms:chest tightness, chest tightness, wheezewheezebreathlessness on exertion, breathlessness on exertion, spontaneous cough and whespontaneous cough and wheeeze during ze during

the night and early morningthe night and early morningrecurrent episodes of frank respiratory recurrent episodes of frank respiratory

infectioninfectionepisodes of severe acute asthmaepisodes of severe acute asthma

Physical signs of asthmaPhysical signs of asthmaChest wall movementChest wall movement

Percussion note Percussion note

Breath soundsBreath sounds

Added soundsAdded sounds

Chest wall movementChest wall movement

Percussion note Percussion note

Breath soundsBreath sounds

Added soundsAdded sounds

reduced on both sidereduced on both side

normal or hyperresonantnormal or hyperresonant

vesicular, prolonged vesicular, prolonged expirationexpiration

expiratory polyphonic expiratory polyphonic wheeze;wheeze;

high-pitched polyhigh-pitched polypphonic honic expiratory and inspiratory expiratory and inspiratory

rhonchi rhonchi

reduced on both sidereduced on both side

normal or hyperresonantnormal or hyperresonant

vesicular, prolonged vesicular, prolonged expirationexpiration

expiratory polyphonic expiratory polyphonic wheeze;wheeze;

high-pitched polyhigh-pitched polypphonic honic expiratory and inspiratory expiratory and inspiratory

rhonchi rhonchi

acute bronchitis acute inflammation of the tracheobronchial tree, generally self-limited and with...

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