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Chronic Obstructive Pulmonary Diseases
Chronic Bronchitis
Emphysema
Acute Bacterial Pneumonias
Primary Bronchogenic Carcinoma
Structure of respiratory system
• Review
– Nose
– Pharynx
– Larynx
– Trachea
– Bronchi
– Bronchioles
– Alveolar ducts
– Alveoli
COPD
Chronic Obstructive Pulmonary
Diseases
A group of diseases with objective evidence
of persisting and irreversible air flow
obstruction.
Chronic bronchitis; bronchiectasis; asthma;
emphysema
Chronic
Bronchiti
s
• Definition
– A persistent productive cough for at least
3 consecutive months in at least 2
consecutive years.
– Main symptoms:
• Cough
• Sputum
• Wheezing
• Etiology
– Chronic irritation by inhaled substances
• Cigarette smoking, air pollution.
– It is common among cigarette smokers and urban
dwellers in smog-ridden cities, especially men of
more than 40 years old.
– These predispose to infection of respiratory
epithelia
– Microbiologic infections
• Bacteria: Haemophilus influenzae,
streptococcus pneumoniae
• Viruses: respiratory syncytial virus,
adenovirus.
Recall of the histology of bronchus
• Epithelium: ciliated
columnar epithelial
cells with a small
number of goblet cells.
• Two types of bronchial
glands.
– One secrets mucus
– the other secrets serum
• Pathogenesis
Cigarette smoking or other air pollutants
→hypersecretion of bronchial mucus glands
→mucin-secreting goblet cells ↑
maintaining inflammation
fibrosis
→narrowing of bronchioles and coexistent
emphysema.
Morphology
• Grossly
– the mucosa is usually hyperemia and swollen
– mucus or mucopurulent secretions
• Histologically
– Injury and repair of mucosa epithelium
• Columnar epithelia: degeneration,
necrosis, desquamation, cilia lost.
• Squamous metaplasia
–changes of glands (feature)
–Mucous glands: hyperplasia and
hypertrophy (the larger glands lead to the
thickening of bronchial walls and narrowing
of bronchial lumina )
–Goblet cells: proliferation.
–Serous glands: begin secreting mucus
– Lesion of bronchial wall
• Inflammatory infiltrate: mononuclear
cells in the absence of infection,
admixed neutrophils when microbe
infects.
• Proliferation of smooth muscle,
degeneration, calcification and
ossification of cartilage.
Pulmona
ry
emphyse
ma
• Definition
– Abnormal permanent enlargement of the
airspaces distal to the terminal
bronchioles accompanied by destruction
of their walls, without obvious fibrosis.
• respiratory bronchiole
• alveolar duct
• alveolus
• Etiology
– heavy cigarette smoking
– Small airway infection: chronic bronchitis
– Air pollution
– Pneumoconiosis
• Incidence
– common, approximately 50% of middle to late
adults
• Pathogenesis
– Chronic airflow obstruction:
• Obstruction of the small airways (often occurs in
chronic bronchitis ) induces increased expiratory
effort to overcome the airways resistance,
compressing the small airways, which lack
cartilaginous support.
• Thus residual air in acini increases to induce the
enlargement of acini.
recall of lung’s histology
– Interstitial emphysema
• Accumulation of air in the
interstitial tissues
–Other types
•Paracicatrical emphysema: near
lung scarring area
•Bullous emphysema: with bulla
(emphysema space more than 1cm in
diameter)
•Senile emphysema: increased
volume of lung often found in
aged
•Compensatory emphysema: alveolar
dilatation that follows collapse
or loss of lung substance
左肺下叶大泡性肺气肿
在全腺泡型肺气肿基础上,有直径超过 1cm 的大囊泡
bullous emphysema
Centriacinar emphysema
• the involvement of the lobule lies in the
central or proximal parts of the acini:
– respiratory bronchioles are affected, while
distal airspaces are spared.
– both emphysematous and normal airspaces
exist within the same acinus and lobule.
Periacinar/Paraseptal emphysema
• Four stages:
– Congestion
– Red hepatization
– gray hepatization
– Resolution
The stage of congestion
• Macroscopically
– the affected lobe(s) is(are) heavy, boggy, red.
Red, edematous
The stage of congestion
• Histologically
– Alveolus walls vascular congestion and
dilation
– alveoli contain proteinaceous fluid, scattered
neutrophils and numerous bacteria
The stage of red hepatization
• Macroscopically
– the lung lobe is distinctly red, firm and airless
with liver-like consistency.
Confluent
consolidation of
all or the majority
of a lobe of the
lung
• Red
• Solid
• Consistency resembling fresh liver
The stage of red hepatization
• Histologically
– Alveolar wall vascular congestion becomes
more evident
– the alveolar spaces are packed with red cells,
fibrin and neutrophils.
– the pleura usually demonstrates a fibrinous or
fibrinopurulent exudate (plueritis).
The stage of gray hepatization
• Macroscopically
– the lung is dry 、 gray 、 firm and liver-like in
consistency.
gray hepatization in
the lower lobe of the
lung
• Dry Pale Firm
The stage of gray hepatization
• Histologically
– Alveolus wall vascular congestion diminishes
– the fibrinous exudate, neutrophils persist and
increase within alveoli
– the number of RBC relatively reduces
(disintegration)
– The pleuritis is most intense.
图注:大叶性肺炎
灰色肝变期,肺泡腔完整,肺泡隔内毛细血管明显扩张充
血。腔内渗出的纤维素网络了大量的中性粒细胞。
灰色肝样变期 ( 低倍 )
灰色肝样变期 ( 高倍 )
The stage of resolution
• Macroscopically
– the lung is edematous (boggy and wet).
• Histologically
– Alveolus wall vascular congestion reoccurs
– Exudates within the alveoli are enzymatically digested
and either reabsorbed or expectorated, leaving the
basic architecture intact.
– The pleural reaction may similarly resolve or undergo
organization, leaving fibrous thickening or permanent
adhesions.
Clinical Course
• The onset is abrupt, with high fever and an
episode of a severe shaking chill
• Chest pain
• A cough productive of rusty-colored purulent
sputum (when?)
• Dyspnea, most severe during the second
stage of red hepatization.
Complications
• Suppurative pleuritis and empyema
• Pulmonary carnification: organization of
the exudate
• Bacteremic dissemination: may cause
septicemia, pyemia or infective shock
• Lung abscess
Pulmonary
carnification
Lobular pneumonia
• Lobular pneumonia has a characteristic
patchy distribution, centered on inflamed
bronchioles and bronchi with subsequent
spread to surrounding alveoli. Because
lobule is made of bronchiole and
surrounding alveoli, we also call lobular
pneumonia bronchopneumonia.
Etiology
• The common agents are staphylococci,
streptococci, pneumococci, Haemophillus
influenza, Pseudomonas aeruginosa, etc.
Incidence
• These people are vulnerable because of
lower defensive mechanism.
– Infants
• With whooping cough, measles.
– The old age
• With influenza, chronic bronchitis, etc.
– People suffering from chronic debilitating
illness or immunosuppression
Morphology
• Macroscopically
– foci of inflammatory consolidation are distributed in
patches throughout one or several lobes, most frequently
bilateral and basal.
– The lesions are gray-red to yellow, varying in size up to
0.5 to 1 cm in diameter, poorly delimited in margin.
– in severe cases, they may confluent.
– The surrounding areas of consolidation is usually
hyperemia and edematous, but the large intervening
areas are generally normal.
Bronchopneumonia
Morphology
• Histologically
– focal suppurative exudate fills the
bronchi 、 bronchioles and adjacent alveolar
spaces.
– The centers of suppurative lesions lie in
bronchi and bronchioles.
Clinical course
• The onset is insidious, often overshadowed
by the predisposing condition.
• Low-grade fever
• Cough with purulent sputum
• Course is irregular, lying on the treatment
and patient’s condition.
• Most can be cured.
Complications
• Respiratory failure
• Heart failure
• Pyemia
• Abscess
小叶性肺炎并发肺脓肿
Primary Lung Tumor
• Primary lung tumor— the tumor arises from
the lung tissue
– 95% from the bronchial epithelium –
bronchogenic carcinomas
– 5% are miscellaneous
Bronchogenic Carcinoma
• Incidence:
– The number one cause of cancer-related deaths
– about 1/3 of cancer deaths in men
– the leading cause of cancer deaths in women
– The peak incidence of lung cancer occurs
between ages 40 and 70 years.
• Etiology and Pathogenesis:
– Cigarette smoking
– air pollution
– Genetic changes
Classification
• Macroscopic Classification
– Central pattern
• the cancers tend to arise centrally in major bronchi.
– Peripheral pattern
• the cancers are usually peripherally located.
– Diffuse pattern
• the cancers are multiple diffuse nodules that may
coalesce to produce pneumonia-like consolidation.
Central pattern
Peripheral pattern
Diffuse pattern
• Histologic Classification
– Non-Small Cell Carcinoma (NSCLC)
• Squamous cell carcinoma
• Adenocarcinoma
• Large cell undiffereniated carcinoma
– Small Cell Lung Carcinoma (SCLC)
– Combined Patterns
• Several common features:
– The majority arise in the lining epithelium of
major bronchi, usually close to the hilus of the
lung.
– All patterns are associated with cigarette
smoking; the strongest association is with
squamous cell and small cell carcinoma.
– All patterns are aggressive
Squamous cell carcinoma
• Incidence:
– the most common histologic pattern
• 30-50% of all lung cancers
• 80-85% of the central pattern
– more common in men than in women
Squamous cell carcinoma
• lMorphology:
– Macroscopically :
• well-defined tumor mass central in major bronchi
– Histologically
hyperplasia→
squamous mateplasia→
atypical hyperplasia of squamous cells→
carcinoma in situ→ squamous cell carcinoma
Squamous cell carcinoma
– Histologically
• squamous cell carcinoma
– Well-differentiated squamous cell
carcinomas show keratin pearls and
intercellular bridges.
– Poorly-differentiated squamous cell
carcinomas have only minimal residual
squamous cell features.
• Metastasis:
– squamous cell carcinoma are prone to
metastasize by lymph
– local hilar lymph nodes are usually affected
Small cell lung carcinomas(SCLC)
• Incidence:
– relatively common (20-25%), and also more
common in men than in women.
• Morphology:
– Macroscopically
• pale, gray, centrally located masses with extension into
the lung parenchyma and early involvement of the hilar
and mediastinal lymph nodes.
Small cell lung carcinomas(SCLC)
• Histologically:
– “oat cell”
• small 、 dark 、 round-to-oval 、 spindle-shaped or
lymphocyte-like cancer cells
• with scant cytoplasm
• with hyperchromatic nuclei
• mitoses are numerous
SCLC
• Metastasis:
– They tend to early metastasize by blood
stream
– SCLCs have invariably spread by the time
they are first detected, even if the primary
tumor appears small and localized.
– They are very sensitive to chemotherapy but
invariably recur.
Traits of SCLC