ACUTE BRONCHITIS Acute inflammation of the tracheobronchial tree, generally self-limited and with...
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Transcript of 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
Acute irritative bronchitisAcute irritative 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.
Acute irritative bronchitisAcute irritative bronchitis
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
Acute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiologyAcute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiology
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
Acute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiologyAcute bronchitis: pathology Acute bronchitis: pathology and pathophysiologyand pathophysiology
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
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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.
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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..
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
Persistent fever Persistent fever
suggests suggests
complicating complicating
pneumoniapneumonia..
Persistent fever Persistent fever
suggests suggests
complicating complicating
pneumoniapneumonia..
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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.
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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.
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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.
Acute bronchitis: Acute bronchitis: symptoms and signssymptoms and signsAcute bronchitis: Acute bronchitis: symptoms and signssymptoms and signs
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
Acute bronchitis:Acute bronchitis:diagnosisdiagnosis
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.
Acute bronchitis:Acute bronchitis:diagnosisdiagnosis
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
obstructionobstruction
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
obstructionobstruction
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
obstructionobstruction
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
COPD: pathologyCOPD: pathology
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.
COPD: pathologyCOPD: pathology
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.
COPD: pathologyCOPD: pathology
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.
COPD: symptoms and COPD: symptoms and signssigns
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.
COPD: symptoms and COPD: symptoms and signssigns
spirometric
screening
of smokers
spirometric
screening
of smokers? !? !
Classification of COPDClassification of COPD
Severity: Severity:
mildmild
moderatemoderate
severe severe
Classification of COPDClassification of COPD
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
Classification of COPDClassification of COPD
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
Classification of COPDClassification of COPD
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
occasionallyoccasionally
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
occasionallyoccasionally
streaked with blood during streaked with blood during infective exacerbationsinfective exacerbations
purulent during bacterial purulent during bacterial infectioninfection
scantyscanty mucoidmucoid tenacioustenacious
occasionallyoccasionally
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
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
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
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
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)
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
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.
BRONCHIAL ASTHMABRONCHIAL ASTHMA
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.
BRONCHIAL ASTHMABRONCHIAL ASTHMA
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.
BRONCHIAL ASTHMABRONCHIAL ASTHMA
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.
BRONCHIAL ASTHMABRONCHIAL ASTHMA
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)
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).
Increased responsiveness of Increased responsiveness of the airways of the lung (airway the airways of the lung (airway hyperreactivity)hyperreactivity)
Increased responsiveness of Increased responsiveness of the airways of the lung (airway the airways of the lung (airway hyperreactivity)hyperreactivity)
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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 .
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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.
Bronchial asthma: clinical Bronchial asthma: clinical featuresfeaturesBronchial asthma: clinical Bronchial asthma: clinical featuresfeatures
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