Andrew Idoko

Group 332
Variant 14
Contrast obstructive and restrictive pulmonary disease, in
terms of pathogenesis, morphological features, radiologic
manifestations and pulmonary function test results.

There are many different obstructive and restrictive lung diseases, some of
which have shared causes, others that don't.

Obstructive
Obstructive lung diseases are characterized by an obstruction in the air
passages, with obstruction defined by exhalation that is slower and shallower
than in someone without the disease.

Obstruction can occur when inflammation and swelling cause the airways to
become narrowed or blocked, making it difficult to expel air from the lungs.
This results in an abnormally high volume of air being left in the lungs (i.e.,
increased residual volume). This leads to both the trapping of air and
hyperinflation of the lungs—changes that contribute to a worsening of
respiratory symptoms.

The following lung diseases are categorized as obstructive:

Chronic obstructive pulmonary disease (COPD)

Chronic bronchitis
Asthma
Bronchiectasis
Bronchiolitis
Cystic fibrosis
Restrictive
In contrast to obstructive lung diseases, restrictive conditions are defined by
inhalation that fills the lungs far less than would be expected in a healthy
person.
Restrictive lung diseases are characterized by a reduced total lung capacity or
the sum of residual volume combined with the forced vital capacity (the
amount of air that can be exhaled forcefully after taking a deep breath).

This occurs because of difficulty filling the lungs completely in the first place.
Restrictive lung diseases can be due to either intrinsic, extrinsic, or
neurological factors.

Intrinsic Restrictive Lung Diseases

Intrinsic restrictive disorders are those that occur due to restriction in the lungs
(often a "stiffening") and include:

Pneumonia
Pneumoconioses
Adult respiratory distress syndrome (ARDS)
Eosinophilic pneumonia
Tuberculosis
Sarcoidosis
Pulmonary fibrosis and idiopathic pulmonary fibrosis
Lobectomy and pneumonectomy (lung cancer surgery)
Extrinsic Restrictive Lung Diseases

Extrinsic restrictive disorders refer to those that originate outside of the lungs.
These include impairment caused by:

Scoliosis
Obesity
Obesity hypoventilation syndrome
Pleural effusion
Malignant tumors
Ascites
Pleurisy
Rib fractures
Neurological Restrictive Lung Diseases

Neurological restrictive disorders are those caused by disorders of the central

nervous system that interfere with movements necessary to draw air into the
lungs. Among the most common causes:
Paralysis of the diaphragm
Guillain-Barré syndrome
Myasthenia gravis
Muscular dystrophy
Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease)
A person may also have symptoms and tests that suggest a combination of
obstructive and restrictive disease (for example, when a person has both COPD
and pneumonia). In addition, some diseases, such as silicosis, cause an
obstructive pattern in the early stages of the disease and a restrictive pattern
when the condition is more advanced.
Symptoms
There can be significant overlap in symptoms between obstructive and
restrictive lung diseases, which is why pulmonary function tests are often
needed to make a diagnosis.2
Symptoms shared by both obstructive and restrictive conditions include:
 Shortness of breath (dyspnea)
 Persistent cough
 Rapid respiratory rate (tachypnea)
 Anxiety
 Unintentional weight loss (due to the increased energy needed to
breathe)
Obstructive Symptoms
With obstruction, a person may have difficulty expelling all of the air from the
lungs. This often worsens with activity, since when respiratory rate increases, it
becomes challenging to blow out all of the air in the lungs before taking the
next breath.
Narrowing of the airways may cause wheezing, as well as increased mucus
(sputum) production.
Restrictive Symptoms
With restrictive lung disease, a person may feel like it is hard to take a full
breath, and this can cause considerable anxiety at times.
With extrinsic lung disease, a person may change positions trying to find a one
that makes it easier to breathe.
Obstructive Disease Symptoms
 Lungs may feel chronically full or part full
 Wheezing
 Mucus production
Restrictive Disease Symptoms
 Feels hard to breathe enough air
 Breathing difficulties may cause panic
  May change positions to attempt to make it easier to breathe (extrinsic
cases)
Diagnosis
Making a diagnosis of either obstructive or restrictive lung disease begins with
a careful history and physical exam, though pulmonary function tests and
imaging tests are very important, especially when the diagnosis is unclear.
These tests can also help doctors understand if more than one condition is
present at the same time, especially when a mixed pattern is found.
Pulmonary Function Tests
Spirometry is a common office test used to evaluate how well your lungs
function by measuring how much air you inhale and how much/how quickly
you exhale. It can be very helpful in differentiating obstructive and restrictive
lung diseases, as well as determining the severity of these diseases.
This test can determine the following:
 Forced vital capacity (FVC): Forced vital capacity measures the amount
of air you can breathe out forcefully after taking as deep a breath as
possible.
 Forced expiratory volume in one second (FEV1): Forced expiratory
volume in one second measures the total amount of air that can be
forcibly exhaled in the first second of the FVC test. Healthy people
generally expel around 75% to 85% in this time. The FEV1 is decreased in
obstructive lung diseases and normal to minimally decreased in
restrictive lung diseases.
 FEV1/FVC ratio: The ratio of FEV1 to FVC measures the amount of air a
person can forcefully exhale in one second relative to the total amount
of air he or she can exhale. This ratio is decreased in obstructive lung
disorders and normal in restrictive lung disorders. In an adult, a normal
FEV1/FVC ratio is 70% to 80%; in a child, a normal ratio is 85% or greater.
The FEV1/FVC ratio can also be used to figure out the severity of
obstructive lung disease.2
 Total lung capacity (TLC): Total lung capacity (TLC) is calculated by
adding the volume of air left in the lungs after exhalation (the residual
volume) with the FVC. TLC is normal or increased in obstructive defects
and decreased in restrictive ones. In obstructive lung diseases, air is left
in the lungs (air trapping or hyperinflation), causing a TLC increase.
There are other types of pulmonary function tests that may be needed as well:
 Lung plethysmography estimates the amount of air that is left in the
lungs after expiration (functional residual capacity) and can be helpful
when there is overlap with other pulmonary function tests. It estimates
how much air is left in the lungs (residual capacity), which is a measure
 of the compliance of the lungs. With restrictive airway disease, the lungs
are often "stiffer" or less compliant.
 Diffusing capacity (DLCO) measures how well oxygen and carbon dioxide
can diffuse between the tiny air sacs (alveoli) and blood vessels
(capillaries) in the lungs. The number may be low in some restrictive lung
diseases (for example, pulmonary fibrosis) because the membrane is
thicker; it may be low in some obstructive diseases (for example,
emphysema) because there is less surface area for this gas exchange to
take place.
Obstructive and Restrictive Lung Patterns
Measurement Obstructive Pattern Restrictive Pattern
Forced vital capacity (FVC)Decreased or normalDecreased
Forced expiratory volume Decreased Decreased or normal
in one second (FEV1)
FEV1/FVC ratio Decreased Normal or increased
Total lung capacity (TLC) Normal or increased Decreased

Treatment
The treatment options are significantly different for obstructive and restrictive
lung diseases, though treatments can vary considerably depending on the
particular root cause.

With obstructive lung diseases such as COPD and asthma, medications that
dilate the airways (bronchodilators) can be very helpful. Inhaled or oral
steroids are also frequently used to reduce inflammation.

Treatment options for restrictive lung diseases are more limited. With extrinsic
restrictive lung disease, treatment of the underlying cause, such as a pleural
effusion or ascites, may result in improvement. With intrinsic restrictive lung
disease such as pneumonia, treatment of the condition may also help. Until
recently, there was little that could be done to treat idiopathic fibrosis, but
there are now drugs available that can reduce the severity.3

Supportive treatment can be helpful for both types of lung diseases and may
include supplemental oxygen, noninvasive ventilation (such as CPAP or BiPAP),
or mechanical ventilation. Pulmonary rehabilitation may be beneficial for those
who have COPD or who have had lung cancer surgery.

When severe, lung transplantation is also sometimes an option.