ACUTE

BRONCHITIS
Acute
Acute inflammation
inflammation of
of the
the
tracheobronchial
tracheobronchial tree,
tree,
generally
generally self-limited
self-limited and
and
with
with eventual
eventual complete
complete
healing
healing and
and return
return of
of
function.
function.

Though
Though commonly
commonly mild,
mild,
bronchitis
bronchitis may
may be
be serious
serious
in
in debilitated
debilitated patients
patients and
and
those
those with
with chronic
chronic lung
lung or
or
heart
PPT To disease.
PDF by
heart DLM Infosoft
disease.
Acute bronchitis:

§ Acute infectious
bronchitis
§ Acute irritative
bronchitis
§ Cough-variant
asthma
PPT To PDF by DLM Infosoft
Acute infectious
bronchitis
§ It may develop after a
common cold or other viral
infection of the
nasopharynx, throat, or
tracheobronchial tree,
often with secondary
bacterial infection.
§ Mycoplasma pneumoniae
and Chlamydia
PPT also
To PDF by DLM cause a.
Infosoft
Acute infectious
bronchitis
§ Recurrent attacks often
complicate chronic
bronchopulmonary diseases,
which impair bronchial
clearance mechanisms.
§ Repeated infections may be
associated with:
§ chronic sinusitis
§ bronchiectasis
§ bronchopulmonary alergy
PPT To PDF by DLM Infosoft
Acute irritative
bronchitis
§ May be caused by various
mineral and vegetable
dusts; fumes from strong
acids, ammonia, certain
volatile organic solvents,
chlorine, hydrogen sulfide,
sulfur dioxide, or bromine;
the environmental
irritants ozone and
PPT To PDF
nitrogen by DLM Infosoft
dioxide; or
Cought-variant
asthma
§ Asthma in which the
degree of
bronchoconstriction is
not sufficient to produce
overt wheezing.
§ It may be caused by
allergen inhalation, or
chronic exposure to an
airways irritant (airways
PPT To PDF by DLM Infosoft
hyperreactivity relatively
Acute bronchitis:
pathology and
pathophysiology
§ Hyperemia of the mucous
membranes

PPT To PDF by DLM Infosoft

Acute bronchitis:
pathology and
pathophysiology
§ The protective functions
of bronchial cilia,
phagocytes, and
lymphatics are disturbed

PPT To PDF by DLM Infosoft

Acute bronchitis:
pathology and
pathophysiology
§ Cough, though distressing,
is essential to eliminate
bronchial secretions
•edema of the
bronchial walls
•retained airways
secretions obstruc
•in same cases → tion
spasm ofPDF by DLM Infosoft
PPT To
Acute bronchitis:
Symptoms and signs
§ Acute infectious
bronchitis is often
preceded by symptoms of
a URI:
Øcoryza
Ø coryza
Ømalaise
Ø malaise
Øchilliness
Ø chilliness
Øslight
Ø slight fever
fever
Ø
Ø back
back and
and muscle
muscle pain
pain
PPT To PDF by DLM Infosoft
 Acute bronchitis:
symptoms and signs
§§ Onset
Onset of
of cough
cough usually
usually signals
signals
onset
onset of
of bronchitis.
bronchitis.

§§ The
The cough
cough is
is initially
initially dry
dry and
and
nonproductive
nonproductive

PPT To PDF by DLM Infosoft

Acute bronchitis:
symptoms and signs

Frankly purulent
sputum suggests
superimposed
bacterial infection
PPT To PDF by DLM Infosoft
Acute bronchitis:
symptoms and signs

In a severe
uncomplicated case,
fever ~38,5ºC may be
present for up to 3
to 5 days, following
PPT To PDF by DLM Infosoft
Acute bronchitis:
symptoms and signs

Though cough may

continue for
several weeks.

PPT To PDF by DLM Infosoft

Acute bronchitis:
symptoms and signs

Persistent
fever
suggests
complicati
ng
PPT To PDF by DLM Infosoft
Acute bronchitis:
symptoms and signs

Dyspnea may
be noted
secondary to
the airways
obstruction.
PPT To PDF by DLM Infosoft
Acute bronchitis:
symptoms and signs

Pulmonary
signs are few
in
uncomplicate
d acute
PPT To PDF by DLM Infosoft
 Acute bronchitis:
symptoms and signs
§ scattered high- or
low-pitched rhonchi
§ occasional crackling
or
§ moist rales at the
bases
§ wheezing, especially
PPT To PDF by DLM Infosoft
Acute bronchitis:
symptoms and signs

§ Persistent
localized signs
suggest
development of
bronchopneum
PPT To PDF by DLM Infosoft
Acute bronchitis:
diagnosis
§ Diagnosis is
usually based on
the symptoms
and signs

If the symptoms
and signs are
serious or
prolonged
PPT To PDF by DLM Infosoft
Acute bronchitis:
diagnosis

§ Arterial blood
gases should be
monitored when
serious
underlying
chronic
PPT To PDF by DLM Infosoft
respiratory
Acute bronchitis:
diagnosis
§ In persons who
do not respond
to antibiotic
therapy, or in
special
circumstances,
Gram stain and
sputum
PPT To PDF culture
by DLM Infosoft
CHRONIC AIRWAYS
OBSTRUCTIVE
DISORDERS
CHRONIC
OBSTRUCTIVE
PULMONARY
DISEASE = COPD

CHRONIC ASTHMATIC
PPT To PDF by DLM Infosoft
COPD
§ This chapter deals with
generalized persistent
airways obstruction
associated with
varying combinations
of chronic bronchitis,
respiratory
bronchiolitis (small
PPT To PDF by DLM Infosoft
airways disease),
 AIRWAYS
OBSRUCTION

increased
resistanc
e to
airflow
during
forced
PPT To PDF by DLM Infosoft
 Its hallmark is slowing of
forced expiration,
producing characteristic
spirometric findings.
It may result from narrowing
or obliteration of airways
secondary to intrinsic
airways disease, from
excessive expiratory
collapse of airways
secondary toDLM
PPT To PDF by pulmonary
Infosoft
Definitions of:

§ CHRONIC BRONCHITIS
§ CHRONIC OBSTRUCTIVE
BRONCHITIS
§ PULMONARY EMPHYSEMA
§ CHRONIC OBSTRUCTIVE
EMPHYSEMA
§ CHRONIC ASTHMATIC
BRONCHITIS
PPT To PDF by DLM Infosoft
Chronic bronchitis

§ a condition associated
with prolonged
exposure to
nonspecific bronchial
irritants and
accompanied by mucus
hypersecretion and
PPTcertain
To PDF bystructural
DLM Infosoft
Chronic obstructive
bronchitis

§ disease of the small

airways of sufficient
degree to lead to
clinically significant
airways obstruction

PPT To PDF by DLM Infosoft

Pulmonary
emphysema
enlargement of the
airspaces distal to the
terminal
nonrespiratory
bronchioles,
accompanied by
destructive changes
PPT To PDF by DLM Infosoft of
Chronic obstructive
emphysema
sufficient loss of lung
recoil to allow marked
airways collapse on
expiration, leading to
the physiologic pattern
of airways obstruction
PPT To PDF by DLM Infosoft
Chronic asthmatic
bronchitis
An underlying asthmatic
problem in patients in
whom the asthma has
become so persistent
that clinically significant
chronic airflow
obstruction is present
PPT To PDF antiasthmatic
despite by DLM Infosoft
§ These
conditions
frequently
coexist and it
may be
difficult in an
individual case
to decide
which is the
PPT To PDF by DLM Infosoft
§ This is
particularly true
in regard to the
combination of
chronic
obstructive
bronchitis and
emphysema,
which is often
PPT To PDF by DLM Infosoft
described with
 Shaded areas
represent patients
with clinically
significant chronic
airways obstruction.
A

Interrelationship
of asthma, small
airways disease,
and persistent
airways
PPT To PDF by
obstruction . DLM Infosoft
DEFINITION OF COPD
A
A CHRONIC,
CHRONIC, SLOWLY
SLOWLY
PROGRESSIVE
PROGRESSIVE DISORDER
DISORDER
CHARACTERISED
CHARACTERISED BY
BY AIRFLOW
AIRFLOW
OBSTRUCTION
OBSTRUCTION
(FEV
(FEV11<80%
<80% PREDICTED
PREDICTED AND
AND
FEV
FEV11/VC
/VC RATIO<70%)
RATIO<70%)
WHICH
WHICH DOES
DOES NOT
NOT CHANGE
CHANGE
MARKEDLY
MARKEDLY OVER OVER SEVERAL
SEVERAL
MONTHS.
MONTHS.
The
The impairment
impairment of
of lung
lung function
function
PPT To PDF by DLM Infosoft
is largely fixed but may be
DEFINITION OF COPD
Historically, the term
„chronic bronchitis” was
used to define any patient
who coughed up sputum
on most days of at least 3
consecutive months for
more than 2 successive
years (provided other
PPT To PDF
causes of by DLM Infosoft
coughhad been
DEFINITION OF COPD

The term „emphysema”

referred to the
pathological process of a
permanent destructive
enlargement of the
airspaces distal to the
terminal bronchioles.
PPT To PDF by DLM Infosoft
 The death rate
from COPD
currently
exceeds
25 000/year
in United Kingdom
(>10-fold higher
than
PPT Toasthma)
PDF by DLM Infosoft
 The basic lesion of
emphysema is believed to
result from the effect on
the alveolar wall of
proteolytic enzymes,
which can be released
from leucocytes
participating in an
inflammatory process.
Thus, any factor leading to
chronic alveolar
inflammation would
PPT To PDF by
encourage DLM Infosoft
development
The single most important
cause of COPD is cigarette
smoking and a direct
correlation exists
between the number of
cigarettes smoked in pack
years
(1 pack year = 20 cigarettes
smoked daily for a year)
and the likelihood of
developing
PPT theInfosoft
To PDF by DLM disease.
Model of annual decline in FEV1
with accelerated decline in
susceptible smokers.

On
On stopping
stopping smoking,
smoking, subsequent
subsequent loss
loss is
is
similar
PPTto
similar to
Tothat
that
PDFin
in healthy
healthy
by DLM non-smokers.
non-smokers.
Infosoft
§ Smoking is thought to
have its effect by
inducing persisting
airway inflammation
and causing a direct
imbalance in
oxidant/antioxidant
capacity and
proteinase/antiprotei
nase load in the lungs.
§ Individual
susceptibility to
smoking is very wide
PPT To PDF by DLM Infosoft
Homozygotic α1-
antitrypsin
deficiency
§ In this rare congenital
condition a persons’s
ability to neutralize
proteases is markedly
diminished

emphysema may develop

by middle age even
without
PPT exposure
To PDF by to
DLM Infosoft
§ A small additional
contribution to the severity
of COPD has been reported
in patients exposed to dusty
or air-polluted
environments.

§ Association between
development of COPD and:
Ø low birth weight
Ø bronchial hyper-
PPT To PDF by DLM Infosoft
responsiveness
COPD: pathology
§ Most patients develop:
Ø airway wall inflammation
Ø hypertrophy of the
mucus-secreting glands
Ø increase in the number
of goblet cells in the
bronchi and bronchioles
Ø decrease in the number
of ciliated cells
PPT To PDF by DLM Infosoft
COPD: pathology
§ Airflow limitation reflects
both mechanical
obstruction in the small
airways and loss of
pulmonary elastic recoil.
§ Loss of alveolar
attachments around such
airways makes them more
liable to collapse during
PPT To PDF by DLM Infosoft
expiration.
COPD: pathology
§ Emphysema is usually
centriacinar, involving
respiratory bronchioles,
alveolar ducts and
centrally located alveoli.
§ More rarely, panacinar
emphysema or paraseptal
emphysema develops,
with the latter
PPT To PDF byfor
responsible DLMblebs
Infosoft
on
COPD: pathology
Pulmonary vascular
remodelling

persistent hypoxaemia

pulmonary hypertensions Cor

and pulmonale
right ventricular
PPT To PDF by DLM Infosoft
hypertrophy
 The
pathology of
emphysema
ç Normal lung

ç Emphysemato
us lung
showing gross
loss of the
normal
PPT To PDF by DLM Infosoft
COPD: symptoms
and signs
§ COPD is
thought to
begin early in
adult life,
though
significant
symptoms
and disability
PPT To PDF by DLM Infosoft
usually do not
COPD: symptoms
and signs
§ Mild
ventilatory
abnormaliti
es may be
discernible
long before
the onset of
significant
PPT To PDF by DLM Infosoft
clinical
COPD: symptoms
and signs
§ Mild spirometric
„smoker’s ?! screening
cough” is of smokers
often
present
many years
before
onset of
PPT To PDF by DLM Infosoft
Classification of
COPD

§ Severity:

ü mild

ü moderate

ü severe
PPT To PDF by DLM Infosoft
Classification of
COPD

§ Mild
ü Spirometry: FEV1 60-
79% predicted

ü Symptoms: smoker’s
cough ± exertional
PPT To PDF by DLM Infosoft
Classification of
COPD
§ Moderate
ü Spirometry: FEV1 40 -
59% predicted

ü Symptoms: exertional
breathlessness ±
wheeze;
PPT To PDF by DLM Infosoft
Classification of
COPD
§ Severe
ü Spirometry: FEV1 <40%
predicted

ü Symptoms:
breathlessness,

PPT Towheeze
PDF by DLMand
Infosoft
§ The disease generally
starts with repeated
attacks of productive
cough, usually after
colds during the
winter months, which
show a steady increase
in severity and
PPT To PDF by DLM
duration Infosoft
with
§ Gradually progressive
exertional dyspnea is
the most common
presenting complaint.
§ Patients may date
onset of dyspnea to an
acute respiratory
illness; the acute
infection may only
unmask a preexisting
PPT To PDF by DLM Infosoft
subclinical chronic
§ Wheezing
§ recurrent
respiratory
may also
infections
be initial
occasionally
§ weakness manifestat
§ weight loss ions
§ lack of libido
PPT To PDF by DLM Infosoft
§ Rarely, initial
complaints are
related to heart
failure secondary to
cor pulmonale,
because some
patients apparently
ignore cough and
dyspnea before
PPT To PDF the
by DLM Infosoft
§ Cough and sputum
production are
extremely variable.
§ One patient may admit
only to „clearing my
chest” on awakening in
the morning or after
smoking the first
cigarette of the day.
PPT To PDF by DLM Infosoft
Sputum may be:
§ scanty
§ mucoid
§ tenacious
occasionally
§ streaked with
blood during
infective
exacerbations
§ purulent during
PPT To PDF by DLM Infosoft
bacterial infection
§ Breathlessness
is aggravated by
infection,
excessive
cigarette
smoking and
adverse
PPT To PDF by DLM Infosoft
§ In patients with mild
to moderate disease
the respiratory
examination may be
normal.
§ However, variable
numbers of
inspiratory and
expiratory rhonchi,
PPT To PDF by DLM Infosoft
§ Crepitations which
usually, but not
always, disappear
after coughing may
be audible over the
lower
PPT Tozones.
PDF by DLM Infosoft
Clinical abnormalities in
patients with advanced
airflow obstruction
§ Rhonchi, especially on
forced expiration
§ A reduction in the length
of the trachea palpable
above the sternal notch
§ Tracheal descent during
inspiration (tracheal
„tug”)
§ Contraction of the
sternomastoid
PPT To PDF by DLMand
Infosoft
Clinical abnormalities in
patients with advanced
airflow obstruction
§ Excavation of the
suprasternal and
supraclavicular fossae
during inspiration,
together with indrawing
of the costal margins and
intercostal spaces
§ Increased antero-
posterior diameter of the
PPT To PDF by DLM Infosoft
chest relative to the
Clinical abnormalities in
patients with advanced
airflow obstruction
§ Loss of weight common
(often stimulates
unnecessary
investigation)
§ Pursed-lip breathing –
physiological response to
decrease air trapping
§ Central cyanosis
§ Flapping tremor
PPT To PDF and
by DLM Infosoft
Clinical abnormalities in
patients with advanced
airflow obstruction

§ Peripheral oedema which

may indicate cor
pulmonale
§ Raised JVP, right
ventricular heave, loud
pulmonary second sound,
tricuspid regurgitation
PPT To PDF by DLM Infosoft
The diagnosis and
classification of
COPD rests on
objective
demonstration of
airways obstruction
by spirometric
testing
PPT To PDF by DLM Infosoft
§ FEV1 < 80% predicted

§ FEV1/VC ratio of <70%

§ little variation in serial

PEF

strongly
PPT To PDF bysuggests
DLM Infosoft
§ Reversibility testing to
salbutamol and
ipratropium bromide is
necessary to detect
patients with
substantial increases
in FEV1 who are really
asthmatic,
PPT To PDF by DLM and to
Infosoft
§ COPD cannot be diagnosed
on a chest radiograph but
this investigation is useful
in excluding other
pathology.
§ In moderate and severe
COPD the chest radiograph
typically shows
hypertranslucent lung
fields with disorganisation
of the vasculature, a low
PPTflat
To PDF by DLM Infosoft
diaphragm or
BRONCHIAL ASTHMA

§ Chronic
inflammatory
disorder of the
airways,
characterised by
reversible airflow
obstruction
causing cough,
PPT To PDF by DLM Infosoft
BRONCHIAL ASTHMA
§ Inflammation of the
bronchial wall involving
eosinophils, mast cells
and lymphocytes,
together with the
cytokine and
inflammatory products
of these cells, induces
hyper-responsiveness
ofPPT
theTo PDF by so
bronchi DLM Infosoft
that
BRONCHIAL ASTHMA
§ Narrowing of the
airway is usually
reversible, but in
some patients with
chronic asthma the
bronchial wall
inflammation may
lead to irreversible
obstruction of
PPT To PDF by DLM Infosoft
BRONCHIAL ASTHMA
§ The airflow
obstruction causes
mismatch of alveclar
ventilation and
perfusion and
increases the work
of breathing.
§ Being more marked
during
PPT Toexpiration
PDF by DLMitInfosoft
BRONCHIAL ASTHMA
§ A narrowed
bronchus can no
longer be effectively
cleared by coughing
up the mucus formed
by the disease
process, and many of
the bronchi become
obstructed
PPT To PDF by mucus
by DLM Infosoft
 Pathological changes in
asthma

Smooth
Smooth
muscle
muscle
hypertroph
hypertroph
y
y and
and
Thickened
Vasodilat
Vasodilat Thickened
hyperplasia
hyperplasia
basement
ation
ation basement
Mucus
Mucus membrane
membrane
plug
plug Oedematous
Oedematous
Desquamation
Desquamation submucosa
submucosa withwith
of
of epithelium
epithelium infiltration
infiltration of
of
Hyperplasia granulocytes
granulocytes
Hyperplasia of
of Infiltration
Infiltration of
of
mucous
mucous glands
glands bronchial
bronchial and
and
parabronchial
parabronchial
tissues
tissues with
with
monocytes
monocytes andand
lymphocytes
lymphocytes
PPT To PDF by DLM Infosoft
BRONCHIAL ASTHMA
§ Bronchial asthma is a
common disease.
ü 15% of children report
an episode of wheezing
characteristic of
asthma within the
previous year
ü 5% have a diagnosis of
asthma
PPT To PDF by DLM Infosoft
§ Long-term follow
-up in developing
countries
suggests that
the disease may
become more
frequent as
individuals
become more
„Westernized”
PPT To PDF by DLM Infosoft
Bronchial asthma:
classification
§ Asthma can be divided
into:
§ Extrinsic – implying a
definite external cause
§ Intrinsic or
cryptogenic – when no
PPT To PDF by DLM Infosoft
causative agent can be
Extrinsic asthma
§ Occurs in atopic
individuals who show
positive skin-prick
reactions to common
inhaled allergens.
§ Positive skin tests to
inhalant allergens are
shown in 90% of
children with asthma,
whereas only 50% of
adults show
PPT To this
PDF by DLM Infosoft
Intrinsic asthma
§ Often starts in middle
age. Nevertheless,
many show positive
skin tests and on close
questioning give a
history of respiratory
symptoms compatible
with childhood asthma
PPT To PDF by DLM Infosoft
§ This classification is of
little value in clinical
practice. Non-topic
individuals may develop
asthma in middle age
from extrinsic causes
such as sensitization to
occupational agents or
aspirin intolerance, or
because they were given
β-adrenoreceptor-
PPT To PDF by DLM Infosoft
 Causes of asthma.
Ato
py
Occupation Viral
al Allergy to
inhalants infections
sensitisers
Rhinovirus
Rhinovirus
Isocyanates
Isocyanates
Parainfluenza
Parainfluenza
Colophony
Colophony virus
virus
fumes
fumes
Atmospheri RSV
RSV
c pollution Cold
Sulphur
Sulphur
air
dioxide
dioxide Emotio
n
Ozone
Ozone
Irritant
Drugs
dusts,
β
β-- vapor and
Adrenorecep
Adrenorecep fumes
tor
tor blocking
blocking
agents PPT
agents To PDF by DLM Infosoft
Perfume
Perfume
Atopy and allergy
§ The term „atopy” was used
by clinicians at the
beginning of the century to
describe a group of
disorders, including asthma
and hay fever, that
appeared:
ü To run in families
ü To have characteristic wealing
skin reactions to common
allergens in the
PPT To PDF environment
by DLM Infosoft
Atopy and allergy
§ The term is now best
used to describe those
individuals who readily
develop antibodies of IgE
class against common
materials present in the
environment.
§ Genetic and environmental
factors affect serum IgE
levels → early childhood
exposure toby
PPT To PDF allergens and
DLM Infosoft
Atopy and allergy
§ Allergens from the
faecal particles of
the house-dust
mite are the most
important extrinsic
cause of asthma
worldwide.
§ The fungal spores
from A. fumigatus
PPT To PDF by DLM Infosoft
Increased
responsiveness of the
airways of the lung
(airway hyperreactivity)
§ Bronchial reactivity can
by demonstrated by
asking the patient to
inhale gradually
increasing concentrations
of histamine or
methacholine (bronchial
PPT To PDF by DLM Infosoft
Increased
responsiveness of the
airways of the lung
(airway hyperreactivity)
§ Patients with clinical
symptoms of asthma
respond to very low doses
of methacholine
(PD20FEV1<11μmol).

PD20FEV1 → the dose of the

PPT To PDF by
agonist DLM Infosoft
(provocation
Bronchial asthma:
clinical features
§ Patients suffering
from asthma exhibit
virtually identical
symptoms to those
suffering from airflow
limitation caused by
chronic bronchitis and
PPT To PDF by DLM Infosoft
emphysema.
Bronchial asthma:
clinical features
§ The symptoms of
asthma consist of a
triad of dyspnea,
cough, and wheezing.
§ In its most typical
form asthma is an
episodic disease, and
PPT To PDF by DLM Infosoft
all three symptoms
Bronchial asthma:
clinical features
§ Bronchial asthma may
be either episodic or
chronic.
§ In episodic asthma the
patient has no
respiratory
symptoms or signs
PPT To PDF by DLM Infosoft
between episodes
Bronchial asthma:
clinical features
§ Attacks:
ü often occur at night,
ü may also abruptly follow
exposure to a specific
allergen, physical
exertion, a viral
respiratory infection, or
emotional
PPT To PDFexcitement.
by DLM Infosoft
Bronchial asthma:
clinical features
§ Attacks:
ü at the onset the patient
experiences a sense of
constriction in the chest,
often with a
nonproductive cough.
PPT To PDF by DLM Infosoft
Bronchial asthma:
clinical features
§ Respiration becomes
audibly harsh, and
wheezing in both phases
of respiration becomes
prominent,
ü expiration becomes
prolonged
ü Patients frequently have
PPT To PDF by DLM Infosoft
tachypnoe, tachycardia,
Bronchial asthma:
clinical features
ü The lungs rapidly become
overinflated, and the
anterior-posterior
diameter of the thorax
increased.

PPT To PDF by DLM Infosoft

Bronchial asthma:
clinical features
ü If the attack is severe
or prolonged, the
accessory become
visibly active and
frequently a
paradoxical pulse will
PPT To PDF by DLM Infosoft
Bronchial asthma:
clinical features
Severe acute
asthma

PPT To PDF by DLM Infosoft

Chronic asthma
§ Symptoms:
ü chest tightness,
ü wheeze
ü breathlessness on exertion,
ü spontaneous cough and
wheeze during the night and
early morning
ü recurrent episodes of frank
respiratory infection
ü episodes of severe acute
asthma
PPT To PDF by DLM Infosoft
Physical signs of
asthma
Chest wall reduced on both side
movement
normal or
Percussion hyperresonant
note
vesicular, prolonged
Breath sounds expiration

expiratory
Added sounds polyphonic
wheeze;
high-pitched
polyphonic
PPT To PDF by DLM Infosoft
expiratory and
PPT To PDF by DLM Infosoft
PPT To PDF by DLM Infosoft