Emphysema

Target: UG medical students.

1. EMPHYSEMA
[COPD - CHRONIC OBSTRUCTIVE
PULMONARY DISEASES]
Dr.CSBR.Prasad, M.D.

2. Clinical presentations
•Dyspnoea
•Recurrent respiratory infections
•Right heart failure

3. Increased air space in the lungs
Main pulmonary change

5. Emphysema
Definition: Abnormal permanent
enlargement of the airspaces distal to the
terminal bronchiole, accompanied by
destruction of their walls and without
obvious fibrosis.
Spaces in parenchyma > 1mm = Abnormal

6. Emphysema
Emphysema causes dilation of air
spaces by destruction of alveolar wall,
leading to collapse of alveoli during
expiration

8. Emphysema & Overinflation
•Emphysema: Increased air space with
destruction
•Overinflation: Increased air space without
destruction

9. Posteroanterior (PA) and lateral chest radiograph in a patient
with severe chronic obstructive pulmonary disease (COPD).
Hyperinflation, depressed diaphragms, increased retrosternal
space, and hypovascularity of lung parenchyma is demonstrated.

10. A lung with
emphysema shows
increased
anteroposterior (AP)
diameter, increased
retrosternal airspace,
and flattened
diaphragms on lateral
chest radiograph.

11. Severe bullous
disease
observed on
CT scan in a
patient with
COPD

12. Classification: Types of emphysema
1. Centriacinar
2. Panacinar
3. Paraseptal [Distal acinar]
4. Mixed & unclassified [Irregular]

13. RB1
Alveoli
Normal
Acinus

15. Centrilobular
Panlobular
Paraseptal
Irregular
TB
RB
A

16. Centriacinar :
[ centrilobular, Proximal acinar ]
•Dilatation of Respiratory Bronchiole
•Upper lobes - severely involved
•Can coexist with chronic bronchitis
•Invariably occurs in smokers
•Coal mine workers [carbon, dust]

17. CENTRIACINAR
FIGURE 15-7 A, Centriacinar emphysema. Central areas
show marked emphysematous damage (E), surrounded by
relatively spared alveolar spaces. B, Panacinar emphysema
involving the entire pulmonary lobule.

18. CENTRIACINAR

19. Panacinar Emphysema:
•Whole of Acinus uniformly affected
• Lower lobes severely involved
•Association:
… A1AT deficiency
… Cigarette smokers

20. PANACINAR

21. Paraseptal (Distal Acinar)
•Localized along pleura - peripheral part
of the acinus
•Predisposes to spontaneous peumothorax
•Adjacent to foci of fibrosis
•Least common

22. Mixed – IRREGULAR EMPHYSEMA:
•MOST COMMON
•LEAST SIGNIFICANT
•COMMON AROUND SCAR TISSUE
•COMBINATION OF TYPES

23. Mixed [CENTRIACINAR + PARASEPTAL]

24. Microscopy of emphysema

25. Emphysema - Microscopy

26. Pathogenesis
•Protease and antiprotease theory
AAT, A1MG
•Oxidant-antioxidant imbalance
SOD, Glutathione

30. Alpha-1 Antitrypsin deficiency
•52 kD serum glycoprotein
•Synthesis: liver, macrophage
•Inhibits - Trypsin, Thrombin, Plasmin, Elastase
•Gene: chromosome 14 [75 alleles]
* Normal allele -- MM (90%)
* Deficiency -- ZZ

31. Pathophysiology

32. Pathophysiology
• Expiratory narrowing of bronchioles >
Air flow obstruction > underventilation

• Mismatch between ventilation & perfusion

• Can lead to chronic cor pulmonale

33. Etiology
• Cigarette smoking [20 - 40% smokers]
• Air pollution
• Alpha-1-antitrypsin deficiency
• Inherited diseases ( Rare )
* Cutis laxa
* Marfan’s syndrome
* Menke’s syndrome

34. Cutis Laxa

35. Marfan’s syndrome

36. Elher Danlos syndrome

37. Menke’s syndrome

38. Other types of emphysema
•Compensatory emphysema
•Senile emphysema
•Obstructive overinflation
•Bullous emphysema
•Interstitial emphysema:
… Trauma to chest wall
… Severe cough

39. Bullae
•Def: Subpleural, air-filled cystic areas
•Size: >1cm
•Location: Anterior margin & Apices

•Complication: Rupture > Pneumothorax

40. Emphysematous
Bullae

41. Fig-1 Bullous emphysema with large subpleural bullae (upper left)
Fig-2 Chronic obstructive pulmonary disease (COPD). Gross pathology of a patient with
emphysema showing bullae on the surface.

42. Irregular Emphysema with Bullae

43. Atelectasis of right lung with shift in mediastinum

44. Clinical picture
•Dysponea
•Cough with or without expectoration
•Wheezing
•Loss of weight
•Peptic ulceration
•Hypercapnia > changes in central
nervous system
•Barrel chest

45. Barrel chest

47. Obstructive Pulmonary diseases
•Disorders Associated with Airflow
Obstruction
•Chronic bronchitis, Emphysema, Asthma,
Bronchiectasis & Bronchiolitis come under
this category

48. Venn diagram of chronic obstructive pulmonary disease (COPD).
Chronic obstructive lung disease is a disorder in which subsets of
patients may have dominant features of chronic bronchitis,
emphysema, or asthma. The result is irreversible airflow obstruction.

49. COPD
•COPD: Comprises Emphysema and chronic
bronchitis
•Many patients have overlapping features of
damage at both the acinar level (emphysema) and
bronchial level (bronchitis)
•Common extrinsic trigger— cigarette smoking —
is implicated in both the diseases

50. Figure 15-9 Schematic representation of evolution of
chronic bronchitis (left) and emphysema (right).

51. Natural history of COPD
•Pathological process (for years)
> clinical symptoms
•Survival is variable
•Respiratory failure > terminal phase of disease
•2/3 dead < 2 years
•DEATH: - Respiratory acidosis and coma
- Chronic cor pulmonale
- Spontaneous pneumothorax

53. “Pink Puffer”
Thin
Dysponea
< Vital capacity
> Lung volume
Emphysema

54. “Blue Bloater” – Chronic bronchitis

55. “Pink Puffers & Blue Bloaters”

56. Table 15-4 -- Emphysema and Chronic Bronchitis


Predominant Bronchitis Predominant Emphysema
Age (yr) 40–45 50–75
Dyspnea Mild; late Severe; early
Cough Early; copious sputum Late; scanty sputum
Infections Common Occasional
Respiratory insufficiency Repeated Terminal
Cor pulmonale Common Rare; terminal
Airway resistance Increased Normal or slightly increased
Elastic recoil Normal Low
Chest radiograph Prominent vessels; large heart Hyperinflation; small heart
Appearance Blue bloater Pink puffer

57. E N D