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KURSK STATE MEDICAL

UNIVERSITY
DEPARTMENT OF PROPAEDEUTICS OF INNER
DISEASES
Acute bronchitis

COPD (COLD)-
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Bronchitis -
an inflammation of the bronchi .

Type according to the course:
Acute
Chronic
Type according to location:
Focal
Diffuse
Type according to inflammation:
Catarrhal
Mucopurulent
Purulent
Fibrinous
Haemorrhagic

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: FEV
1,
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
(FEV
1
< 80% predicted,
FEV
1
/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).
6
th
place among the leading death causes in the
world (5
th
Europe, 4
th
- 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.

PATHOGENESIS
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)
Reid index
The airway epithelium is characterized by the
squamous metaplasia, atrophy of ciliated cells,
hypertrophy of the mucus glands
(Quantitation of the anatomic change)
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.
Breathlessness
exertional dyspnea,
later episodes of sleep apnea.
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 S
2.
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 V
1-2
.
Increased S wave in V
5-6
.
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
(CO
2
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 size of 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.

Features
Predominant emphysema Predominant bronchitis
Type A Pink puffer Type B Blue bloater
Age at time of
diagnosis
60 50
Dyspnea Severe Mild
Cough After dyspnea starts Before dyspnea starts
Sputum Scanty, mucoid Copious, purulent
Bronchial infections Less frequent More frequent
Respiratory
insufficiency episodes
Often terminal Repeated
X-ray
"Hyperinflation"
bullous changes,
small heart
Increased bronchovascular
markings at bases, large
heart.
Chronic PaCO
2
mmHg
35-40 50-60
Chronic PaO
2
mmHg 65-75 45-60
Hematocrit % 35-45 50-55
Pulmonary hypertension

Features
Predominant emphysema Predominant bronchitis
Type A Pink puffer Type B Blue bloater
Rest None to mild Moderate to severe
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
High risk
Stage 1 Stage 2 Stage 3 Stage 4
Risk
factors

Chronic
productive
cough

Normal
functional
tests
FEV
1
/FLVC
<70%


FEV
1
>80%


Chronic
productive
cough
FEV
1
/FLVC
<70%

FEV
1
>50%
or
FEV
1
<80%

Chronic
productive
cough
FEV
1
/FLVC
<70%

FEV
1
<50%
or
FEV
1
>30%

Chronic
productive
cough
FEV
1
/FLVC
<70%

FEV
1
<30%

Chronic
respiratory
insufficiency
&/or
Right cardiac
failure
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,
B
2
-stimulating sympathomimetics,
anticholinergics
Corticosteroids
Schematic representation of the morphology of normal airways and lung parenchyma
and the changes produced in this structures by asthma, chronic bronchitis, and
emphysema.
Mucous gland
hyperplasia
Inflammatory
cellular
infiltration

Schematic representation of the morphology of normal airways and lung parenchyma
and the changes produced in this structures by asthma, chronic bronchitis, and
emphysema.
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Intrapulmonary
Airway