THE RESPIRATORY SYSTEM

The LUNGS are ingeniously constructed to carry out their cardinal function– the exchange of
gases between the inspired air and the blood. The normal adult lung weighs approximately 300-400
grams.
The two lower lobes present almost entirely on the posterior aspect of the thoracic cavity,
while the upper lobes and (R) middle lobe present almost entirely on the anterior aspect.
The Main Stem Bronchus is more vertical and more directly in line with the trachea than the
(L). As a consequence, aspirated foreign material such as vomiting, blood and foreign bodies tends to
enter the (R) lung rather than the (L).
In the Trachea and Major Bronchi, the cartilage takes the form of C-shaped plates leaving the
posterior membranous portion free of cartilage. Smooth muscle is present only in the membranous
portion.
However, as the main bronchi enter the lungs, this organization changes; discontinuous plates of
cartilage and muscle now encircle the entire wall.
Progressive branching of the Bronchi forms Bronchioles which are differentiated from Bronchi by the
lack of cartilage and submucosal glands within their walls.
Further branching of Bronchioles leads to the Terminal Bronchioles, which are less than 2mm in
diameter.
The part of the lung distal to the Terminal Bronchioles is called “Acinus” or the “Terminal
Respiratory Unit” which is approximately spherical in shape with a diameter of about 7mm. The Acini
contain Alveoli and are thus the site of gas exchange.

AN ACINUS IS COMPOSED OF:

1. Respiratory Bronchioles which give off from their sides several alveoli; it then proceeds into,
2. Alveolar Ducts which immediately branch and empty into the;
3. Alveolar Sacs, the blind ends of the respiratory passages whose walls are formed entirely of alveoli.

# ACUTE ADULT RESPIRATORY DISTRESS (ARDS)

Synonyms: (Adult Respiratory Failure; Shock Lung; Diffuse Alveolar Damage (DAD), Alveolar Injury,
Traumatic Wet Lung)
• ARDS and its many synonyms are descriptive terms used for a syndrome characterized
clinically by the rapid onset of dyspnea, tachypnea, cyanosis and severe arterial
hypoxemia (deficient O2 in the blood) which is refractory to oxygen therapy.
• In the majority of patients with ARDS, there is evidence of severe pulmonary edema,
lung compliance is decreased and chest x-rays usually show a diffuse alveolar
infiltration.
• The lungs are usually heavy and boggy (wet spongy). In addition to the changes of
pulmonary congestion and edema described earlier, the Alveolar walls are lined with
thick waxy Hyaline membranes identical to those seen in hyaline membrane disease in
neonates.
• This hyaline membrane consist of protein-rich, fibrin-rich edema fluid admixed with
the cytoplasmic and lipid remnants of necrotic epithelial cells.
# ATELECTASIS:
Atelectasis refers either to incomplete expansion of the lungs or the collapse of the previously
inflated lung substance. OR it is the collapse of the expanded lung or a defective expansion of the
pulmonary alveoli at birth.
• This disorder may be present at birth, may arise during the first days of post-natal life,
or it may occur anytime thereafter, or an acquired disorder.
• Whenever it occur, it is characterized by areas of relatively airless pulmonary
parenchyma.

@
ATELECTASIS NEONATORUM
Atelectasis in the newborn is divided into Primary and Secondary forms.
Synonyms with Primary atelectasis is “Congenital Atelectasis”, implying that the lungs or some
significant portion of them failed to expand at birth.
The Secondary form of atelectasis results when adequate inflation occur but is followed soon
thereafter by collapse.

@ ACQUIRED ATELECTASIS
This form of disease, encountered principally in adults, maybe divided into “Obstructive” and
“Compressive” Atelectasis which may involve ALL lobes (massive atelectasis) which is usually
incompatible with life.
Obstructive Atelectasis is the consequence of complete obstruction of an airway which in time, leads
to absorption of the O2 trapped in the dependent alveoli, followed by their collapse.
Compressive Atelectasis results whenever the pleural cavity is partially or completely filled by fluid
exudates, tumor, blood clot or air that may constitute a Pneumothorax. In compressive atelectasis,
the mediastinum shifts away from the affected lung.

@ CHRONIC OBSTRUCTIVE PULMONARY DISEASE: (COPD)

The term “Chronic Obstructive Pulmonary Disease” (COPD), refers to a group of conditions such as
Emphysema, Chronic Bronchitis, Bronchial Asthma and Bronchiectasis that are accompanied by
chronic or recurrent obstruction to air flow within the lungs.

* Because of the increased in environmental pollutants, cigarette smoking and other noxious
exposures, the incidence of COPD has increased dramatically in the past two decades and it now
represents one of the major causes of morbidity and mortality in the Western world.

@ PULMONARY EMPHYSEMA
Pulmonary Emphysema is defined as a condition of the lungs characterized by abnormal permanent
enlargement of the air spaces distal to the Terminal Bronchiole, accompanied by destruction of their
walls.
(condition of the lung marked by abnormal enlargement of the alveoli with loss of pulmonary
elasticity).//// a condition characterized by air-filled expansions of body tissues)
* Enlargement of the air spaces unaccompanied by destruction is termed as “Overinflation”

Types of Emphysema:
1. Centrilobular (Centriacinar) Emphysema.
The distinctive feature of this type of emphysema is the pattern of involvement of the lobules; the
central or proximal parts of the acini formed by the respiratory bronchioles are affected, while the
distal alveoli are spared.
This lesion is more common and usually severe in the upper lobes particularly in the apical
segments, with the walls of the emphysematous spaces often contain large amounts of black pigment
with inflammation around the bronchi and bronchioles and in the septa.
Centrilobular Emphysema is predominantly a disease of males and is rarely encountered in
nonsmokers.
2. Panlobular (Panacinar) Emphysema
In this type, the acini are uniformly enlarged from the level of the respiratory bronchioles to the
terminal blind alveoli.
It is important to emphasize that the term “PAN” refers to the entire acinus but not the entire
lung.
Panlobular emphysema tends to occur more commonly in the lower zones and in the anterior margins
of the lung and is most severe at the bases of the lungs.

3. Paraseptal (Distal Acinar) Emphysema

In this type, the proximal portion of the Acinus is normal but the distal part is dominantly
involved. The emphysema is more striking adjacent to the pleura along the lobular connective
tissue septa and at the margins of the lobes.
The characteristic findings of Paraseptal Emphysema are of multiple, continuous enlarged
spaces from less than 0.5mm to more than 2.0mm in diameter, sometimes forming a cyst-like
structures.

4. Irregular Emphysema
Irregular emphysema, so named because the Acinus is irregularly involved, and is almost invariably
associated with scarring. Thus, it may be the most common form of emphysema since careful research
of most lungs at autopsy would show one or more scars.
Adjacent to such scars, there is usually irregular enlargement of Acini accompanied by
destructive changes.

OTHER TYPES OF EMPHYSEMA

• Compensatory Emphysema – is sometimes used to designate dilatation of alveoli in response

to loss of lung substance elsewhere.
It is best exemplified in the hyper-expansion of the residual lung parenchyma that follows surgical
removal of a diseased lung or diseased lobe.
 • Senile Emphysema – refers to the over-distended, sometimes voluminous lungs found in the
aged. The lungs appears overinflated on histologic sections and grossly.
Likewise, there is alteration of the internal geometry of the lung--- larger alveolar ducts and smaller
alveoli.

• Obstructive Overinflation – refers to the condition in which the lung expands because air is
trapped within it.
A common cause is obstruction by a tumor or foreign object and a classic example is so-called
“Congenital Lobar Overinflation” of Infants. This is a congenital anomaly probably due to hypoplasia
(arrested development of an organ/structure) of bronchial cartilage and is sometimes associated with
other congenital cardiac and lung abnormalities.

OVERINFLATION IN OBSTRUCTIVE LESIONS OCCUR EITHER:

1. Because of a ball-valve action of the obstructive agent, so that air enters on
inspiration but cannot leave on expiration.
2. Because the bronchus may be totally obstructed but ventilation through “collaterals”
may bring air from behind the obstruction.

• Bullous Emphysema – refers merely to any form of emphysema that produces large sub-
pleural blebs or bullae (an emphysematous spaces more than 1cm in diameter in the distended
state. Bullae represents localized accentuations of one of the four forms of emphysema, are
most often subpleural and occur near the apex, sometimes in relation to old tuberculous
scarring.

• Interstitial Emphysema.
The entrance of air into the connective tissue stroma of the lung, mediastinum or subcutaneous tissue
is designated as “Interstitial Emphysema”
In most instances, alveolar tears in pulmonary emphysema provide the avenue of entrance of the air
into the stroma of the lung, rarely, a wound of the chest that sucks air or a fractured rib that puncture
the lung substance may underlie this disorder.
* Usually, alveolar tears occur when there is a combination of coughing plus some bronchiolar
obstruction producing sharply increased pressures within the alveolar sacs.
* In all these instances, the tear is presumably widened by the dilatation of the full inhalatory
effort, but as the lung collapses in expiration, the tear closes and blocks the escape of air.

CHRONIC BRONCHITIS

Chronic Bronchitis – a lung continued, recurrent inflammation due to repeated attacks of acute
bronchitis or to chronic general disease.

Chronic Bronchitis is present in any patient who has persistent cough with sputum production
for at least three months in at least two consecutive years. While both sexes and all ages may be
affected and is most frequent in middle-aged men.
Two Sets of Factors are Important in the Genesis of Chronic Bronchitis:
1. Chronic Irritation by Inhaled Substances
2. Microbiologic Infection

• Cigarette smoking remains the paramount etiologic influence.

• Chronic Bronchitis is 4 to 10 times more common in heavy smokers, irrespective of age,
sex, occupation and place of dwelling.
• Heavy cigarette smoking alone will induce excessive mucus secretion, destroy normal
ciliary action of the respiratory epithelium and further cause squamous metaplasia and
atypical dysplasia.
• The characteristic histologic feature of chronic bronchitis is enlargement of the
mucussecreting glands of the trachea and bronchi.
• Although Goblet cells increases slightly, the major increase is in the size of the mucous
glands. This increase can be assessed by the ratio of the relative thickness of the
mucous gland layer compared with the thickness of the wall between the epithelium
and the cartilage.

BRONCHIAL ASTHMA

Asthma is a disease characterized by increased irritability of the Tracheo-bronchial tree,

potentiating paroxysmal narrowing of the bronchial airways which may reverse spontaneously or as a
result of treatment.
Bronchial Asthma is a particularly distressing disease because those affected unpredictably experience
disabling attacks of severe dyspnea and wheezing triggered by sudden episode of bronchospasm.

ASTHMA HAS TRADITIONALLY BEEN DIVIDED INTO TWO BASIC TYPES

• Extrinsic Asthma (allergic, regain-mediated, Atopic)
• Intrinsic Asthma ( Idiosyncratic)

# The largest group is so-called “Reaginic or Atopic” asthma wherein these patients is triggered by
environmental antigens such as dusts, pollens, animal dander and foods.
# A positive family history of atopy is common and asthmatic attacks are often preceded by allergic
rhinitis, urticaria or eczema.

# The second large group is the non-atopic or non reaginic variety of asthma which is most frequently
triggered by respiratory tract infection.
# Grossly, the lungs are over distended owing to overinflation and there may be small areas of
atelectasis. # The most striking macroscopic finding is occlusion of bronchi and bronchioles by thick,
tenacious mucus plugs.

BRONCHIECTASIS
 Bronchiectasis is a chronic necrotizing (localized death of tissue) infection of the bronchi and
bronchioles leading to or associated with abnormal dilatation of these airways.
It is manifested clinically by cough, fever and the expectoration of copious amounts of foulsmelling
purulent sputum.
Bronchiectatic involvement of the lungs usually affects the lower lobes bilaterally, particularly those air
passages which are most vertical.
The histologic findings vary with the activity and chronicity of the disease.

* In the full-blown active case, there is an intense acute and chronic inflammatory exudation within
the walls of the bronchi and bronchioles associated with desquamation (to peel off) of the lining
epithelium and extensive areas of necrotizing ulceration.

BACTERIAL PNEUMONIA

Bacterial invasion of the lung parenchyma evokes exudative solidification (consolidation) of the
pulmonary tissue is known as “Bacterial Pneumonia”.
Many variables such as the specific etiologic agent, the host reaction and the extent of the
involvement, determine the precise form of the Pneumonia.
Thus, classification may be made according to etiologic agent (e.g. Pneumococci or
Staphylococcal Pneumonia), the nature of the host reaction (e.g. suppurative, fibrinous, etc.) of the
anatomic distribution of the disease (lobular (Bronchopneumonia), Lobar or Interstitial Pneumonia).
BRONCHOPNEUMONIA (LOBULAR PNEUMONIA)

Patchy consolidation of the lung is the dominant characteristic of Bronchopneumonia.

This parenchymal infection usually represents an extension of a pre-existing Bronchitis or
Bronchiolitis.
It is an extremely common disease that tends to occur in the more vulnerable two extremes of life---
infancy and old age.
Bronchopneumonia consist of a non-specific, suppurative inflammatory response in a loose alveolar
tissue that offers little resistance of the accumulation of large amounts of exudates as well as free
avenue of spread.
Well-developed lesion are slightly elevated, dry, granular, gray-red to yellow and poorly
delimited at their margins that vary in size up to 3-4 cm in diameter.
When caused by such pyogenic organisms as staphylococci, small abscesses can be seen. And with
subsidence, the consolidation may resolve if there has been no abscess formation or may become
organized to leave residual foci of fibrosis.

LOBAR PNEUMONIA

Is an acute bacterial infection of a large portion of a lobe or of an entire lobe which tends to occur at
any age but is relatively uncommon in infancy and in late life.
Males are affected more often than females in the ratio of about 3 or 4 to 1 and about 90 to
95% of all Pneumonias are caused by Pneumococci.
 Lobar Pneumonia consists in essence, of a widespread fibrinous suppurative consolidation of a
large areas and even whole lobes of the lungs.

LUNG ABSCESS

The term Pulmonary Abscess describes a local suppurative process within the lung characterized by
necrosis of lung tissue which may develop at any age and are especially frequent in young adults.
Abscess vary in diameter from a few millimeters to large cavities of 5-6cm.
They may affect any part of the lung and be single or multiple. Pulmonary abscesses due to aspiration
of infective material are much more common on the (R) side than on the (L) and are most often single.
Abscesses usually occur close to or in contact with the pleura that begin as a focus of
inflammation followed in time by central necrosis.
The manifestations of Pulmonary abscesses are much like those of Bronchiectasis and are
characterized principally by cough, fever and copious amounts of foul-smelling purulent or
sanguineous (bloody) sputum.

PULMONARY TUBERCULOSIS

Pulmonary Tuberculosis is an acute or chronic communicable disease caused by

“Mycobacterium Tuberculosis” which principally involved the lungs but may affect any organ or tissue
in the body.

3 Strains of Tubercle Bacilli are Pathogenic for Man:

1. Human Strain
2. Bovine Strain
3. Avian Strain
The Human strain is transmitted to a susceptible (unresistant) host usually by inhalation of infective
droplets coughed or sneezed into the air by a patient with acute or chronic tuberculosis who has open
lesions.
The bacilli are highly resistant to drying and remain viable even in dried sputum particles for weeks. If
infective sputum remains moist, viability may persist for months.
The Bovine strain is transmitted by milk from diseased cows and so first produces intestinal
tuberculosis.
For all practical purpose, the Avian strain can be considered to be non-pathogenic for man. *
Mycobacterium Tuberculosis is causative agent which is a slender curved rod averaging 4 micrometer
in length and less than 1 micrometer in diameter.

HYPERSENSITIVITY PNEUMONITIS

The term Hypersensitivity Pneumonitis includes several conditions in which an interstitial reaction in
the lung is believed to be immunologically mediated by an external antigens.

TWO WELL RECOGNIZED TYPES OF “HYPERSENSITIVITY PNEUMONITIS”

 1. Inhalant Hypersensitivity Pneumonitis
2. Drug Reaction Pneumonitis

A classic example of Hypersensitivity Pneumonitis due to inhalation is so-called “Farmer’s Lung

Disease”– a disease that results from exposure to material generated from harvested, humid, warm
hay, which permit the rapid proliferation of fungi and bacteria.
Hypersensitivity Pneumonitis induced by drugs is less well characterized, except perhaps for the
reaction to the metabolic Nitrofurantoin. The reaction occur while the drug is discontinued and can be
induced by readministration of the compound.

TUMORS OF THE LUNG

BRONCHOGENIC CARCINOMA:

Bronchogenic Carcinoma is preeminent (importance) among great variety of tumors that may arise in
the most often in and about the Hilus of the lung.
About ¾ of the lesions take origin from first, second and third order bronchi.
In its development, carcinoma of the lung begins as an areas of in situ cytologic atypia which,
over an unknown interval of time, yields a small area of thickening or pilling up of the bronchial
mucosa.
With progression, this small focus, usually less than 1cm in area assumes the appearance of an
irregular, warty excrescence that elevates or erodes the lining epithelium.

PLEURA

Inflammation of the Pleura (Pleuritis/Pleurisy) depending upon their stage and causative
agent, can be divided on the basis of the character of the resultant exudates into Serous, Fibrinous,
Serofibrinous, Suppurative and Hemorrhagic Pleuritis.