DISEASES OF DISEASES OF RESPIRATORY SYSTEM RESPIRATORY SYSTEM

The Department of Pathology The Department of Pathology Zili Lv Zili Lv

吕自力吕自力E-mail:lvzili@yahoo.com.cnE-mail:lvzili@yahoo.com.cn

Go overGo over PneumoniaPneumonia

Air space pneumonia

Interstitial pneumonia

lobar pneumonia

lobular pneumonia

viral pneumonia

mycoplasma pneumonia

Respiratory system diseases 2Respiratory system diseases 2

• Chronic (diffuse) obstructive passage disease

• Chronic cor pulmonale

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CChronic hronic OObstructive bstructive PPulmonary ulmonary DDiseases, COPDiseases, COPD

• Chronic bronchitis 慢性支气管炎 *

• Pulmonary emphysema 肺气肿 *

• Bronchial asthma 支气管哮喘• Bronchiectasis 支气管扩张症

Chronic BronchitisChronic Bronchitis

Definition:

A persistent productive cough, sputum for at least 3 months in at least 2 consecutive years.

The most common disease in respiratory system. More common in old age (<40 )

Most cases caused by smoking

A. Etiology and Pathogenesis

Causes:

1. Cigarette smoking: 90%

2. Air pollution: sulfur dioxide and nitrogen dioxide, may contribute.

3. Microorganism infection is often present but plays a secondary role.

Etiology and PathogenesisEtiology and PathogenesisSmoking

Pollution

Infection

Destroy the defensive mechanisms

Hypertrophy of mucous glands

Metaplasia of squamous

Infiltration of inflammatory cells

B. Pathology*B. Pathology*

• The inflammation of trachea and larger bronchi

Grossly:

Hyperemia,

Edema,

Mucous or mucopurulent secretion

Histology Histology

• The injury and regeneration of epithelia.

• The hypertrophy, hyperplasia and metaplasia of mucus-secreting glands. (Reid I >0.5)

• Infiltration with chronic and acute inflammatory cells.

上皮损伤与修复上皮损伤与修复

Squamous metaplasiaSquamous metaplasia

An increase of goblet cellsAn increase of goblet cells

C. Clinical FeaturesC. Clinical Features

• Cough

• Sputum

• Puff

Secretion

D. Complications

BronchiectasisBronchopneumonia

Cor pulmonale

Chronic bronchitis

Pulmonary emphysema

Pulmonary EmphysemaPulmonary Emphysema肺气肿肺气肿

• Emphysema : Permanent enlargement of the

airspaces distal to the terminal bronchioles.

Accompanied by destruction of their walls.

A. Classification of emphysemaA. Classification of emphysema

Alveolar

Interstitial: The air comes into the septa of the lung.

Centriacinar （腺泡中央型）

Periacinar （腺泡周边型）

Panacinar （全腺泡型）

Others type

Centriacinar腺泡中央型

Heavy smokers

Panacinar 全腺泡型

A1-AT deficiency

Periacinar 腺泡周围型

B. Pathology*•Grossly: pale and voluminous lungs

Normal lungs emphysema

Bullous lung

肺大泡• Balloon-like

• >10 mm in diameter

are prone to rupture causing spontaneous pneumothorax

自发性气胸

HistologyHistology

1.Thinning and destruction of alveolar walls, septa broken, adjacent alveoli become confluent.2. Terminal and respiratory bronchioles may be deformed.3. The number of alveolar capillaries decreases.

Thinning and destruction of alveolar walls, large airspaces

C. Pathogenesis* C. Pathogenesis*

• Proteases

• Anti-proteases

• Leukocytes

• Smoking, Inflammation

• Alfa1-antitrypsin

• Inheritance

D. Clinical FeaturesD. Clinical Features

• Cough : dry or productive

• Dyspnea

• Mucoid sputum

• Type A: Pink puffers

• Type B: Blue bloaters

• Barrel chest

桶状胸

Relationship between chronic bronchitis and emphysema

chronic bronchitis and emphysema usually co-exist because the major pathogenic mechanism, cigarette smoking, is common to both.

Bronchial Asthma Bronchial Asthma 支气管哮喘支气管哮喘

• Increased responsiveness of tracheobronchial tree to a variety of stimuli.

• Bronchiolar smooth muscle contraction (bronchospasm 支气管痉挛 ).

• Paroxysmal attacks 阵发性• Mucus plugs in bronchi

A. Etiology and pathogenesisA. Etiology and pathogenesis Hypersensitivity

Inflammation

Hyper-reactive airways

Nerve system

Bronchial smooth muscle spasm

Hypersecretion—mucus plugs

Increased vascular permeability

B. Clinical FeaturesB. Clinical Features——episodic attacksepisodic attacks

• Dyspnea （呼吸困难）• Wheezing （喘）• Dry cough

4. BRONCHIECTASIS4. BRONCHIECTASIS支气管扩张症支气管扩张症

• Permanent dilation of bronchi and bronchioles

• Results from bronchial obstruction with distal infection and scarring

• Destruction of alveolar walls, especially interstitial elastin, and fibrosis of lung parenchyma

Chronic inflammation

The destruction of the wall

Dilation

Congenital, hereditary

Obstruction

Fibrosis Fibrosis

Pathology, GrossPathology, Gross

1) Lower lobes of bilateral lungs are 1) Lower lobes of bilateral lungs are more common, particularly left side more common, particularly left side

2) The airways may be dilated to as 2) The airways may be dilated to as much as much as four timesfour times their usual their usual diameter diameter

3) The dilated bronchioles can be seen almost to 3) The dilated bronchioles can be seen almost to the pleura.the pleura.

PathologyHistological

•Destruction of the bronchial or bronchiolar walls

•Acute and chronic inflammatory exudate within the walls of the bronchi and bronchioles

•Ulceration formation: the desquamation of lining epithelium cause extensive areas of ulceration.

•Fibrosis of the bronchial and bronchiolar walls (in chronic cases).

•Lung abscess.

Clinical FeaturesClinical Features• Cough

• Mucopurulent sputum

• Hemoptysis （咯血）• Finger-clubbing

• Dyspnoea

• Clubbing: 杵状指

• Normal • Clubbing

ComplicationsComplications

• Pneumonia, lung abscess

• Emphysema

• Remote abscesses

• Pulmonary hypertension

• Chronic cor pulmonale

Chronic cor pulmonale Chronic cor pulmonale 慢性肺源性心脏病慢性肺源性心脏病

• A heart disease results from chronic lung diseases, chest or pulmonary vascular diseases.

• Pulmonary hypertension( 肺动脉高压 ).

• Thickened right ventricle( 右心室肥厚 ).

A. Etiology and pathogenesis

1) Recurrent pulmonary emboli

2) Heart disease:

3) Chronic obstructive or interstitial lung disease:

Chronic obstuctive pulmonary disease

Abnormalities of the pulmonary vasculature

Pulmonary arteriolar constriction

Disorders affecting chest movement

Pulmonary vascular bed

Pulmonary hypertension*

Right ventricle hypertrophy

• Key • Key

B. Pathology

Lung

•Existed lung diseases:

•Medium-sized muscular arteries: proliferation of myo-intimal cells and smooth muscle cells, causing thickening of the intima and media with narrowing of the lumina

•Smaller arteries and arterioles: thickening, medial hypertrophy, and reduplication of the internal and external elastic membranes.

B. Pathology

Heart*

•Right ventricle hypertrophy:

•More than 1 cm in thickness (normal 0.3-0.4cm)

•More than 500—700 gm

•The right ventricle and atrium may be dilated when failure occurs

Clinical featuresClinical features

• Cyanosis: hypoxemia

• Pulmonary encephalopathy （肺性脑病）

• Right-sided congestive heart failure--- congestion, edema of lower extremities, palpitation, ascites

SUMMARYSUMMARY • COPD: Chronic bronchitis* Asthma Pulmonary emphysema* Bronchiectasis

• Pulmonary hypertension

• Chronic cor pulmonale*

• 65, woman, cough with purulent sputum after

catching cold 15 years ago.

• She developed cough and expectoration of

white spumy sputum every winter and spring.

•

• Since 3 years ago, she felt breath shortness and

palpitation （心悸） after physical labor.

•Pitting edema （水肿） occurred

repeatedly on her lower limbs for 2 years.

•Two months ago after catching cold, she

developed fever, cough with purulent

sputum, palpitation, breath shortness, and

abdominal distension （膨隆） , and could

not lie down.

Physical examination:

• T: 37.6 , HR:102 times/min, R: 30 ℃times/min.

•

• Chronic sickness appearance, up-straight sit breathing （端坐呼吸） , sleepiness, dark purple lip and skin, cervix venous engorgement （颈静脉怒张）

Chest: Barrel-shape chest, hyper-resonance（过清音） to percussion （叩诊） , scattered dry and moist rales （啰音） .

Abdomen: Abdominal bulge, a large amount of ascites （腹水） , the liver is hard with the rim under the rib 7.8 cm, lower limbs show pitting edema.

QuestionsQuestions

• 1. what is the pathological diagnosis of the patient?

• 2. how to explain the process of the development of the diseases about the patient.

Pathological diagnosisPathological diagnosis

• Chronic bronchitis

• Emphysema

• Chronic cor pulmonale

complicated with:

(1) right heart failure---- liver congestion, lower limbs edema, ascites

(2) pulmonary encephalopathy

The relationshipThe relationship

• Chronic bronchitis---- emphysema----

chronic cor pulmonale----

right heart failure and pulmonary encephalopathy.

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