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Case 5: Anatomical Pathology (Reversible and Irreversible Airway Disease),…

- - - - Intrinsic Asthma
        
        Outline the characteristic of Intrinsic Asthma
        
        Intrinsic Asthma may develop at any age, often between 25-40 years
        
        Intrinsic Asthma predominantly occurs in Females
        
        There is no evidence of Hypersensitivity to Inhaled or Ingested Substances
        
        The prognosis in Intrinsic Asthma is not favorable as that of Extrinsic Asthma
        
        Differentiate between Allergic and Non-Allergic Asthma
        
        Allergic Asthma
        
        Symptoms are associated with an Allergic Reaction
        
        May be triggered by Allergens such as dust, pets, Dander
        
        Non-Allergic Asthma
        
        Symptoms are not associated with an Allergic Reaction
        
        May be triggered by exercise, stress, certain medicine, cold or dry air, Airway infections, Smoke, And other irritants
        
        List the Similarities between Allergic and Non-Allergic Asthma
        
        The Allergic and Non-Allergic Asthma have similar symptoms
        
        Coughing
        
        Shortness of Breath or Difficulty Breathing
        
        Wheezing
        
        Tightening or pain in the Chest Wall
        
        Morphology of Asthma
        Explain the Morphology of the Asthma
        
        Examination of the Sputum shows:
        
        Desquamated Respiratory epithelial Cells
        
        Eosinophils, Mucus
        
        Curschmann's Spirals
        
        Charcot-Leyden Crystals
        
        Describe Curschmann's Spirals
        
        Curschmann's Spirals are Coiled Basophilic plugs of mucus formed in the Lower Airways and found in the Sputum and Tracheal Washings
        
        Describe Charcot-Leyden Crystals
        
        Charcot-Leyden Crystals are Eosinophilic Needle-Shaped Crystalline structures
        
        Postmortem Findings in status asthmaticus shows:
        
        Lungs grossly overinflated
        
        Numerous grey plugs of Exudate occlude the air passages
        
        Asthma
        Outline the microscopic Findings of Asthma
        
        Plugs occluding the Bronchial Lumen
        
        Desquamated Bronchial muscosal cells showing Metaplastic Change
        
        Pronounced Thickening of Basement Membrane
        
        Dilated Congested Capillaries
        
        Oedema and Eosinophilic Infiltrate
        
        Hypertrophy of Bronchial Smooth muscle
        
        Hypertrophied Mucous Glands
        
        Give reasons why the Viscid, Tenacious Plugs of Exudate within the Airways are difficult to clear
        
        Failure to clear the Viscid, Tenacious Plugs of Exudate within the Airways is due to the:
        
        Excessive and Rapid production of Exudate
        
        Quality of Exudate
        
        Loss of Ciliary action
- - - - COPD includes the diagnosis of:
        
        Chronic Bronchitis
        
        Emphysema
        
        Explain what is Chronic Bronchitis and Emphysema
        
        Chronic bronchitis
        
        Chronic bronchitis refers to Cough with Sputum on most days for 3 consecutive months for at least 2 years in a row
        
        In Chronic Bronchitis there is Inflammation of Bronchi which causes narrowing of Bronchi, Coughing, Wheezing, and Chest Tightness
        
        Emphysema
        
        Emphysema is the abnormal permanent enlargement of Air Spaces Distal to the Terminal Bronchioles, accompanied by the destruction of their walls, without obvious Fibrosis
        
        Chronic Bronchitis
        
        Thick, sticky mucous blocks up the airways rather than clears
        
        Inflammation and swelling further narrows airways
        
        Inflammation and excess mucous
        
        Emphysema
        
        Air exchange becomes difficult in the damaged Alveoli
        
        Air becomes trapped
        
        Alveolar membranes are broken down
        
        Pathophysiology of Chronic Bronchitis
        Outline the Pathological Changes in the Airways in Chronic Bronchitis
        
        There is an increased number of Mucous secreting Goblet Cells in the Bronchial mucosa
        
        In advanced cases of Chronic Bronchitis, Bronchi become inflamed and a Pus is seen in the lumen.
        
        Microscopically:
        
        Chronic Inflammatory cells are seen in the wall of the Bronchi, Lymphocyte Infiltration of CD8+ is seen
        
        Columnar Cells are replaced by Squamous Epithelial Cells
        
        Inflammation is followed by scaring and thickening of the wall which causes narrowing of the small air ways
        
        Loss of Interstitial Support
        
        In Chronic Bronchitis the Inflamed Lining the Bronchial Tube, Thick mucus results in a narrowed airways
        
        With Chronic Bronchitis, the lining may stay inflamed and the Cilia may not function
        
        Emphysema
        Define Pulmonary Emphysema
        
        Pulmonary emphysema is described as the abnormal, permanent enlarge (increase is size) of the airspaces Distal to the Terminal Bronchioles, accompanied by destructive of their walls without obvious Fibrosis
        
        In Pulmonary emphysema air exchange becomes difficult in the Alveoli as a result the air becomes trapped
        
        List the types Emphysema (CFPPPB)
        
        Centrilobular (Centriacinar/Proximal acinar) Emphysema
        
        Focal Dust Emphysema
        
        Panacinar (Panlobular) Emphysema
        
        Paracicatricial Emphysema
        
        Paraseptal (Distal) Emphysema
        
        Bullous Disease of the Lung
        
        Describe Centrilobular Emphysema
        
        In Centrilobular Emphysema the abnormal air spaces are formed in the central portions of the Secondary Lobules, and are formed from diseased and largely destroyed Respiratory Bronchioles
        
        Centrilobular Emphysema affects the upper zones more frequently and with greater severity than the lower zones
        
        Centrilobular Emphysema occurs mostly in Males over the age of 40 years
        
        Describe the Microscopic Features of Centrilobular Emphysema
        
        In Centrilobular Emphysema:
        
        Inflammation around the Bronchi, Bronchioles and Septal is usual
        
        Parent Airway is often stenosed causing the inability to dilate or elongate with Inspiration
        
        Describe Focal Dust Emphysema
        
        Focal Dust Emphysema occurs in all individuals exposed to Carbon Dioxide dust inhalation
        
        Focal Dust Emphysema results in Fusifom (spindle-shaped) Dilation of all orders of the Respiratory Bronchioles
        
        The distribution in Focal Dust Emphysema is more Uniform than with Centrilobular Emphysema
        
        There is no inflammation of stenosis of the air-ways
        
        Describe Panacinar (Panlobular) Emphysema
        
        In Panlobular (Panacinar) Emphysema the emphysematous process affects the Acinus in a uniform manner
        
        Panlobular Emphysema results in the permanent enlargement, initially of the Alveolar Ducts and Alveoli, and subsequently of the Respiratory Bronchioles
        
        The Lower Lobes are more frequently affected than the Upper Lobes
        
        Describe the Microscopic Features of Panlobular Emphysema
        
        In Panlobular Emphysema:
        
        Total Disorganisation of the Acinar architecture
        
        Which is replaced by large thin-walled spaces of Irregular size and shape
        
        There is NO inflammation
        
        Describe Paracicatricial Emphysema
        
        In Paracicatricial Emphysema the formation of scars within the Lung Parenchyma is frequently accompanied by the formation of Emphysematous Spaces
        
        The abnormal air spaces lack any special distribution within the Acinus or Lobule
        
        Adjacent scarring increases the elastic pull on the Alveoli
        
        Bronchiolar narrowing caused by Fibrosis and Inflammation results in Air-Trapping
        
        Describe Paraseptal (Distal Acinar) Emphysema
        
        Paraseptal Emphysema is localised to zones adjacent to the Interlobular Septa or Pleura
        
        Describe Bullous Disease of the Lung
        
        Bullous Disease of the Lung involves the Lung Apices
        
        Large air filled cysts occur which are in communication with the rest of the Intra-pulmonary gas
        
        They may co-exist with other forms of Emphysema or occur in isolation with the normal underlying lung emphysema
        
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- - - - Respiratory Failure
        Outline Respiratory Failure in COPD
        
        In COPD, Respiratory Failure occurs when there is a PaO2 less than 8kPa (60 mmHg) or the PaCO2 is greater than 7 kPa (55 mmHg)
        
        Chronic Alveolar Hypoxia and Hypercapnia leads to constriction of Pulmonary Arterioles and Pulmonary Hypertension
        
        NOTE: Respiratory Failure is Type 1 and Type 2
        
        In Type 1: PaO2 is Low and the PaCO2 is Normal or Low
        
        This is caused by Pneumonia
        
        In Type 2: PaO2 is Low and the PaCO2 is High
        
        This is caused by COPD, Respiratory centre depression eg: Drugs
        
        In Type 2 Respiratory Failure, the PaCO2 is elevated and the patient is dependent on their Hypoxic Drive
        
        Therefore, O2 (Oxygen gas) Therapy is given with care
        
        Cor Pulmonale
        Define Cor pulmonale
        
        Cor pulmonale is Right Ventricular Hypertrophy (Failure) secondary to Lung disease (Pulmonary Hypertension)
        
        On examination, the patient is Centrally Cyanosed due to Lung disease
        
        There is a Left Para-Sternal Heave that is felt due to the Right Ventricular Hypertrophy
        
        A Loud P2 (Pulmonary second sound)
        
        Signs of Right Ventricular Failure include:
        
        Increase in JVP
        
        Ascites
        
        Liver enlargement
        
        Peripheral Oedema
        
        FEV 1 is reduced in COPD
        
        Define the FEV 1
        
        FEV 1 is the Volume of air which can be forcibly exhaled from the lungs in the 1st second of the Forced Expiratory Manoeuvre
        
        Explain the Interpretation of FEV 1
        
        FEV 1 is interpreted as a percentage of predicted and can be used to indicate the degree of Obstruction:
        
        If FEV1 is greater than 75% it Normal
        
        If FEV1 is between 60%-75% then there is Mild Obstruction
        
        If FEV1 is between 50%-59% then there is Moderate obstruction
        
        If FEV1 is less than 49% then there is Severe Obstruction
        
        Other Investigations
        List other investigations that are useful on COPD
        
        Chest X-ray: Shows signs of Hyperinflation of the Lungs with Low flattened diaphragm
        
        High resolution CT scan
        
        Haemoglobin and PCV (Packed cell Volume) may be increased due to secondary Polycythaemia
        
        Blood gases show Hypoxaemia and Hypercapnia
        
        Sputum examination may show Streptococci pneumoniae and H. Influenza produced by Acute exacerbations
        
        ECG show Right ventricular Hypertrophy due to a Tall P wave (Pulmonary Hypertension)
        
        Echocardiography to assess cardiac function
        
        alpha1-antityrpsin Level
        
        Management of COPD
        List the strategies in the management of COPD
        
        Smoking cessation
        
        Drug therapy
        
        DT is used for a Short-term management of Exacerbations and Long-term management
        
        Use of Bronchodilators such as
        
        Beta 2 agonist eg: Salbutamol
        
        Anti-muscarinic drugs eg: Ipratropium
        
        Theophylline
        
        Corticosteroids
        
        Antibiotics
        
        Diuretics
        
        Oxygen Therapy
        
        Treatment options for COPD in order of Increasing Severity:
        
        Self-management Education and Smoking cessation
        
        Bronchodilators
        
        Inhaled Corticosteroids
        
        Pulmonary rehabilitation
        
        Oxygen
        
        Surgery
        
        Oxygen Therapy
        
        The purpose of Oxygen therapy is to provide continuous O2 in 2L/minute via nasal prongs to achieve Oxygen gas saturation of greater than 90%
        
        O2 is give for 15-19 hours daily at home
        
        Nocturnal Hypoxia
        
        COPD patients get severe Arterial Hypoxaemia during REM sleep and the PaO2 may fall very low
        
        Most COPD death occur at night possibly due to Cardiac Arrhythmias due to Hypoxaemia
        
        Treatment for Nocturnal Hypoxia
        
        Patients should not be given sleeping tablets as they will depress respiratory drive
        
        Patient should be given O2 (oxygen gas) at night and Ventilatory Support for example:
        
        BIPAP (Bi-level Positive Airway Pressure)
        
        BIPAP is a non-invasive positive pressure ventilation given by a tight fitting nasal mask
        
        It provides inspiratory and expiratory assistance
        
        Pulmonary Rehabilitation
        
        Smoking cessation:
        
        Exercise training such as walking
        
        Physiotherapy
        
        Nutritional advice
        
        Vaccine - Pneumococcal, Influenza