Target: UG medical students.

1. EMPHYSEMA
[COPD - CHRONIC OBSTRUCTIVE
PULMONARY DISEASES]
Dr.CSBR.Prasad, M.D.

2. Clinical presentations
• Dyspnoea
• Recurrent respiratory infections
• Right heart failure

3. Main pulmonary change
Increased air space in the lungs

5. Emphysema
Definition: Abnormal permanent
enlargement of the airspaces distal to the
terminal bronchiole, accompanied by
destruction of their walls and without
obvious fibrosis.
Spaces in parenchyma > 1mm = Abnormal

6. Emphysema
Emphysema causes dilation of air
spaces by destruction of alveolar wall,
leading to collapse of alveoli during
expiration

8. Emphysema & Overinflation
• Emphysema: Increased air space with
destruction
• Overinflation: Increased air space without
destruction

9. Posteroanterior (PA) and lateral chest radiograph in a patient
with severe chronic obstructive pulmonary disease (COPD).
Hyperinflation, depressed diaphragms, increased retrosternal
space, and hypovascularity of lung parenchyma is demonstrated.

10. A lung with
emphysema shows
increased
anteroposterior (AP)
diameter, increased
retrosternal airspace,
and flattened
diaphragms on lateral
chest radiograph.

11. Severe bullous
disease
observed on
CT scan in a
patient with
COPD

12. Classification: Types of emphysema
1. Centriacinar
2. Panacinar
3. Paraseptal [Distal acinar]
4. Mixed & unclassified [Irregular]

13. RB1
Normal
Acinus
Alveoli

15. A
RB Centrilobular
TB
Panlobular
Paraseptal
Irregular

16. Centriacinar :
[ centrilobular, Proximal acinar ]
• Dilatation of Respiratory Bronchiole
• Upper lobes - severely involved
• Can coexist with chronic bronchitis
• Invariably occurs in smokers
• Coal mine workers [carbon, dust]

17. CENTRIACINAR
FIGURE 15-7 A, Centriacinar emphysema. Central areas
show marked emphysematous damage (E), surrounded by
relatively spared alveolar spaces. B, Panacinar emphysema
involving the entire pulmonary lobule.

18. CENTRIACINAR

19. Panacinar Emphysema:
• Whole of Acinus uniformly affected
• Lower lobes severely involved
• Association:
… A1AT deficiency
… Cigarette smokers

20. PANACINAR

21. Paraseptal (Distal Acinar)
• Localized along pleura - peripheral part
of the acinus
• Predisposes to spontaneous peumothorax
• Adjacent to foci of fibrosis
• Least common

22. Mixed – IRREGULAR EMPHYSEMA:
• MOST COMMON
• LEAST SIGNIFICANT
• COMMON AROUND SCAR TISSUE
• COMBINATION OF TYPES

23. Mixed [CENTRIACINAR + PARASEPTAL]

24. Microscopy of emphysema

25. Emphysema - Microscopy

26. Pathogenesis
• Protease and antiprotease theory
AAT, A1MG
• Oxidant-antioxidant imbalance
SOD, Glutathione

30. Alpha-1 Antitrypsin deficiency
• 52 kD serum glycoprotein
• Synthesis: liver, macrophage
• Inhibits - Trypsin, Thrombin, Plasmin, Elastase
• Gene: chromosome 14 [75 alleles]
* Normal allele -- MM (90%)
* Deficiency -- ZZ

31. Pathophysiology

32. Pathophysiology
• Expiratory narrowing of bronchioles >
Air flow obstruction > underventilation
• Mismatch between ventilation & perfusion
• Can lead to chronic cor pulmonale

33. Etiology
• Cigarette smoking [20 - 40% smokers]
• Air pollution
• Alpha-1-antitrypsin deficiency
• Inherited diseases ( Rare )
* Cutis laxa
* Marfan’s syndrome
* Menke’s syndrome

34. Cutis Laxa

35. Marfan’s syndrome

36. Elher Danlos syndrome

37. Menke’s syndrome

38. Other types of emphysema
• Compensatory emphysema
• Senile emphysema
• Obstructive overinflation
• Bullous emphysema
• Interstitial emphysema:
… Trauma to chest wall
… Severe cough

39. Bullae
• Def: Subpleural, air-filled cystic areas
• Size: >1cm
• Location: Anterior margin & Apices
• Complication: Rupture > Pneumothorax

40. Emphysematous
Bullae

41. Fig-1 Bullous emphysema with large subpleural bullae (upper left)
Fig-2 Chronic obstructive pulmonary disease (COPD). Gross pathology of a patient with

42. Irregular Emphysema with Bullae

43. Atelectasis of right lung with shift in mediastinum

44. Clinical picture
• Dysponea
• Cough with or without expectoration
• Wheezing
• Loss of weight
• Peptic ulceration
• Hypercapnia > changes in central
nervous system
• Barrel chest

45. Barrel chest

47. Obstructive Pulmonary diseases
• Disorders Associated with Airflow
Obstruction
• Chronic bronchitis, Emphysema, Asthma,
Bronchiectasis & Bronchiolitis come under
this category

48. Venn diagram of chronic obstructive pulmonary disease (COPD).
Chronic obstructive lung disease is a disorder in which subsets of
patients may have dominant features of chronic bronchitis,
emphysema, or asthma. The result is irreversible airflow obstruction.

49. COPD
• COPD: Comprises Emphysema and chronic
bronchitis
• Many patients have overlapping features of
damage at both the acinar level (emphysema) and
bronchial level (bronchitis)
• Common extrinsic trigger— cigarette smoking —
is implicated in both the diseases

50. Figure 15-9 Schematic representation of evolution of
chronic bronchitis (left) and emphysema (right).

51. Natural history of COPD
• Pathological process (for years)
> clinical symptoms
• Survival is variable
• Respiratory failure > terminal phase of disease
• 2/3 dead < 2 years
• DEATH: - Respiratory acidosis and coma
- Chronic cor pulmonale
- Spontaneous pneumothorax

53. “Pink Puffer”
Emphysema
Thin
Dysponea
< Vital capacity
> Lung volume

54. “Blue Bloater” – Chronic bronchitis

55. “Pink Puffers & Blue Bloaters”

56. Table 15-4 -- Emphysema and Chronic Bronchitis
Predominant Bronchitis Predominant Emphysema
Age (yr) 40–45 50–75
Dyspnea Mild; late Severe; early
Cough Early; copious sputum Late; scanty sputum
Infections Common Occasional
Respiratory insufficiency Repeated Terminal
Cor pulmonale Common Rare; terminal
Airway resistance Increased Normal or slightly increased
Elastic recoil Normal Low
Chest radiograph Prominent vessels; large heart Hyperinflation; small heart
Appearance Blue bloater Pink puffer

57. E N D