KURSK STATE MEDICAL UNIVERSITY

DEPARTMENT OF PROPAEDEUTICS OF INNER DISEASES

Acute bronchitis
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD (COLD)-

Bronchitis an inflammation of the bronchi .

Acute Chronic Focal Diffuse

Type according to the course: Type according to location:

Catarrhal Mucopurulent Purulent Fibrinous Haemorrhagic

Type according to inflammation:

Acute bronchitis
An acute inflammation of the mucous membranes of the trachea and the bronchial tree that follows infections of the upper respiratory tract (< 1month)

Acute bronchitis
Aetiology

Adenovirus Influenza Para influenza Rhinovirus Coxsackie virus Mycoplasma Chlamidia bordetella Haemophilus influenza Moraxella catarrhalis Streptococci Fungi (rare)

Risk factors

COPD Chronic sinusitis Hypertrophy of the oropharynx and tonsils Presence of the tracheostoma Allergy Immunodeficiency Smoking Alcoholism Reflux-esophagitis Air pollutions Children and aged persons

Pathological anatomy.

Hyperemia and swelling of the bronchial mucosa Hypersecretion of mucus Diapedesis of leucocytes Desquamation of epithelium and formation of erosions Inflammation may involve the sub-and muscular layers of the bronchial walls and peribronchial interstitial tissues (grave bronchitis)

Symptoms

Discomfort in the throat and retrosternal smarting. Hoarse voice. Intoxication: weakness, excess perspiration, subfebrile fever, muscular pain. Cough dry or with expectoration of scant tenacious sputum; may be coarse, resonant, barking (in excruciating attacks). Sputum 2-3 day of the disease: first mucopurulent, sometimes with streaks of scarlet blood; then - purulent.

Objective examination:

Temperature - normal or subfebrile Dyspnoea & tachypnea Palpation & Percussion: unchanged Auscultation: harsh breathing dry buzzing and whistling rales (wheezes & ronchi) During resolution (tenacious sputum is thinned by the action of proteolytic enzymes): moist rales with dry rales

Investigations:

X-ray: unchanged. The leukocyte count of the blood: rise 9000-11000 in one microlitre. ESR slightly increased. Sputum: mucous / mucopurulent (sometimes with streaks of blood) contains columnar epithelium and other cell elements. Fibrin clots (bronchial casts) - in acute fibrous bronchitis. Culture (to determine aetiology). Viruses / Mycoplasma Ab. Functional pulmonary tests: FEV1, PEF.

COPD (COLD)
Chronic obstructive pulmonary (lung) disease - a condition with chronic obstruction to airflow due to chronic bronchitis and / or emphysema (most often present in combination)

COPD
Definition:

Chronic, slowly progressive disorder characterized by airflow obstruction (FEV1 < 80% predicted, FEV1/VC ratio < 70%) which does not change markedly over several months

COPD

Over 10% of all hospital admissions Males are more often affected than females (20% of adult males):
9.34/1000 men 7.33/1000 women (WHO)

Age > 40 y.o.

The death rate 25000 / year (>20-fold higher than asthma). 6th place among the leading death causes in the world (5th Europe, 4th - USA)

AETIOLOGY
Contributory factors
Smoking - Particularly of cigarette. Pack years=1 packet of cigarette/day x number of years (1 pack- 20 cigarettes). Smoking index: <100 - mild smoker 101-300 - moderate > 300 - heavy smoker Air pollution: Dust, Smoke, Fumes Infections. Familial and genetic factors (deficient or absent serum levels of 1-antitripsin).

CHRONIC BRONCHITIS

characterized by productive cough on most of the days for at least 3 consecutive months for > 2 consecutive years (exception of others causes of productive cough: bronchiectasis & chronic asthma)

Infection

Morbidity, mortality & frequency of acute respiratory illnesses (viruses, Mycoplasma,

bacteria Haemophilus influenzae, Str. pneumoniae) higher in patients with

chronic bronchitis.

Rhinoviruses often during exacerbation.

Hypertrophy of the mucus-secreting glands, an increase in the number of goblet cells in the bronchi and bronchiole with a consequent decrease in ciliated cells. Less efficient transport of the increased mucus in the airways. Mucosal oedema and permanent structural damage of the airway walls reduce the caliber of the air passages. Air is trapped in the alveoli because the degree of obstruction is greater during expiration, which leads to over-distension of the alveoli resulting in disruption of their walls (emphysema)

PATHOGENESIS

The airway epithelium is characterized by the squamous metaplasia, atrophy of ciliated cells, hypertrophy of the mucus glands (Quantitation of the anatomic change)

Reid index

Ratio of the thickness of submucosal glands to that of the bronchial wall. Normal = 0.44 + 0.09 COPD = 0.52 + 0.08

Morphology of normal airways and in bronchitis.

CLINICAL FEATURES Symptoms

Cough
Initially productive cough - during winter, later - constant. Tightness in the chest in the morning (disappeared by coughing).

Expectoration

Sputum may be little, mucoid and tenacious or cup of mucopurulent / purulent.

exertional dyspnea, later episodes of sleep apnea.

Breathlessness

OBJECTIVE EXAMINATION

Blue Bloater:
overweight, edematous, cyanotic.

Smokers signs
90% COPD patients tobacco smokers Tar stains (nicotine is colorless)

Hair discoloration

Finger clubbing & Hippocratic nails

(in purulent infection)

RESPIRATORY SYSTEM EXAMINATION

Inspection: 1) respiratory rate is normal or slightly increased. 2) there is no apparent usage of accessory muscles. 3) flapping tremor (asterixis) Palpation: hyperinflated chest with reduced expansion. Percussion: resonant sound.

Auscultation:

Hush breathing

(prolonged expiration)

Coarse ronchi & wheezes may be non-consonating crackles

(change in location / intensity after a deep and productive cough)

CARDIOVASCULAR SYSTEM EXAMINATION

Cor pulmonale Cardiac beat. Epigastric pulsation. Bounding pulse, tachycardia, dilatation of the peripheral veins Right heart border shifted to the right. Accentuation of S2. In the presence of right ventricular failure there are often an early diastolic gallop and a holosystolic murmur, both of which are accentuated by inspiration.

DECOMPENSATED COR PULMONALE

Central cyanosis (due to desaturation and erythrocytosis). Peripheral edema. Neck vein distantion, positive jugular pulse. Enlargement of the liver. Positive Plash's sign (hepatojugular reflux) Ascitis. Hydrothorax. Hydropericardium.

X-ray

Diaphragms - well rounded Bronchovascular markings increased in the lower lung fields Cardiac silhouette enlarged Pulmonary arteries - more prominent

ECG:

Increased P wave in III and AVF leads (P-pulmonale) Increased R wave in V1-2. Increased S wave in V5-6. Right limb block of His bundle.

ECHOCARDIOGRAPHY

Pulmonary hypertension. Hypertrophy and dilation of the right ventricle. Tricuspid regurgitation.

Ophthalmologic examination

Papilloedema result of increased cerebral and retinal blood flow (CO2 retention)

Pulmonary function tests:

FEV1 reduced. FEV1/VC decreased. PEF reduced.

COMPLICATIONS
Secondary polycythemia. Pulmonary hypertension / right ventricular failure (cor pulmonale). Hypoxia -> Pulmonary arteriolar vasoconstriction -> Pulmonary hypertension. Type I / Type II respiratory failure.

EMPHYSEMA

Distention of the air spaces distal to the terminal bronchiole with destruction of alveolar septa Reduced lung elasticity

Types of emphysema

Centriacinar
involving the respiratory bronchioles and alveolar ducts in the center of the acinus.

Panacinar
involving the entire acinus

Paraseptal
involving alveolar ducts & sacs farther out in the acinus

Emphysema

Centriacinar: Result of chronic cigarette smoking Upper lung zones involvement Panacinar: A1-antitrypsin deficiency Bases of the lungs involvement

CLINICAL FEATURES Symptoms

Increasing breathlessness - an exertional dyspnea (long history). Minimal cough with small amounts of mucoid sputum. Mucopurulent exacerbations with infections (infrequent).

OBJECTIVE EXAMINATION
Pink puffer Tachypnea with prolonged expiration trough pursed lips / expiration with grunting sound
Lips tightly apposed at height of inspiration, Lips held narrowly apart during expiration

OBJECTIVE EXAMINATION Respiratory system

Asthenic constitution with weight loss. Barrelshaped chest

(increased anteroposterior diameter).

Use of accessory muscles in respiration. Tachypnea. Prolonged expiration through pursed lips. Lower intercostal spaces retract with each inspiration. Neck veins distended during expiration.

OBJECTIVE EXAMINATION Respiratory system

Palpation:

Increased rigidity Decreased vocal fremitus Diminished excursion

OBJECTIVE EXAMINATION
Percussion: Hyperresonant (bandbox) sound Upper borders protruded Lower borders: descendent limited mobility Decreased liver & cardiac dullness Auscultation: diminished vesicular breathing (diffuse dry rales in bronchitis)

OBJECTIVE EXAMINATION Cardiovascular system

Cardiac dullness severely reduced. Decreased heart sounds. Presystolic gallop accentuated during inspiration.

Pulmonary function tests:

The TLC and RV are increased. The VC is low. The maximal expiratory flow rates are diminished.

X-ray of the chest:

Diaphragm is low and flattened. Bronchovascular shadow do not extend to the periphery of the lungs. Cardiac silchouette is lengthened and narrowed. Overinflation.

Predominant emphysema Features Age at time of diagnosis Dyspnea Cough Sputum Bronchial infections Respiratory insufficiency episodes X-ray Chronic PaCO2 mmHg Chronic PaO2 mmHg Hematocrit %

Predominant bronchitis

Type A Pink puffer

60 Severe After dyspnea starts Scanty, mucoid Less frequent Often terminal "Hyperinflation" bullous changes, small heart 35-40 65-75 35-45

Type B Blue bloater

50 Mild Before dyspnea starts Copious, purulent More frequent Repeated Increased bronchovascular markings at bases, large heart. 50-60 45-60 50-55

Pulmonary hypertension
Predominant emphysema Features
Rest

Predominant bronchitis Type B Blue bloater

Moderate to severe

Type A Pink puffer

None to mild

Exercise

Moderate

Worsens

Cor pulmonale

Rare, except terminally

Common

Elastic recoil

Severely decreased

Normal

Resistance

Normal to slight increase

High

Stages of COPD
Stage 0 Stage 1
High risk
Risk factors Chronic productive cough Normal functional tests FEV1/FLVC <70% FEV1/FLVC <70% FEV1>50% or FEV1<80% Chronic productive cough FEV1/FLVC <70% FEV1<50% or FEV1>30% Chronic productive cough FEV1/FLVC <70% FEV1<30% Chronic respiratory insufficiency &/or Right cardiac failure

Stage 2

Stage 3

Stage 4

FEV1>80%

Chronic productive cough

Treatment of COPD

Stop smoking. Nutritional improvement. Exercises Preventive vaccination against influenza virus strains Pneumococcal polysaccharide vaccine (once in life time) Early treatment of the infections (broad spectrum antibiotics 7-10 days) Bronchodilator drugs:
methylxantines, B2-stimulating sympathomimetics, anticholinergics

Corticosteroids