Pulmonary

Pathophysiology

Histology of the lung

Respiratory epithelium
Connective tissue fibers, and cartilage:
support and maintain open air way
Alveolar cells (type I and type II)

Type I
pneumocyte

Type I
pneumocyte
Alveolar
space

Capillary
lumen
Type II
pneumocyte
Endothelium

Normal Lung

Function of the lung

Gas exchange
Protection against infection by alveolar macrophages
Surfactant secretion: allow expansion of alveoli with air

Lung function tests

Tidal volume (TV): it is the amount of gas
inhaled or exhaled with each resting breath.
Residual volume (RV): it is the amount of gas
remaining in the lungs at the end of maximum
exhalation.

 Vital capacity (VC): it is the total amount of

gas that can exhaled following maximum
inhalation.
Total lung capacity (TLC): it is the amount of
gas in the lung at the end of maximum
inhalation.
TLC = RV+ VC

Reduction of Pulmonary
Function

Inadequate blood flow to the lungs:

hypoperfusion

Inadequate air flow to the alveoli:

hypoventilation

Noso-comial infections
Factors that reduce airflow also compromise
particle clearance and predispose to infection.
High rate of pneumonia in hospital patients due
in large part to impaired ventilation and
clearance.

 Restricted lung movement and ventilation

may arise due to:
Positioning
Constricting bandages
Central nervous system depression
Coma

Signs and Symptoms of Pulmonary

Disease

1- Dyspnea: subjective sensation of

uncomfortable breathing, feeling short of
breath
Ranges from mild discomfort after exertion to
extreme difficulty breathing at rest.
Usually caused by diffuse and extensive rather
than focal pulmonary disease.

Causes of Dyspnea :
Airway obstruction
Greater force needed to provide adequate
ventilation
Wheezing sound due to air being forced
through airways narrowed due to constriction
or fluid accumulation

Decreased compliance of lung tissue

Signs of dyspnea:
Flaring nostrils
Use of accessory muscles in breathing
Retraction (pulling back) of intercostal spaces

2- Cough
Attempt to clear the lower respiratory
passages by forceful expulsion of air
Most common when fluid accumulates in
lower airways

Causes of Cough:
Inflammation of lung tissue
Increased secretion in response to mucosal irritation
Inhalation of irritants
Intrinsic source of mucosal disruption such as tumor
invasion of bronchial wall

Excessive blood hydrostatic pressure in pulmonary

capillaries
Pulmonary edema excess fluid passes into airways

 When cough can raise fluid into pharynx, the

cough is described as a productive cough, and
the fluid is sputum.
Production of bloody sputum is called hemoptysis
Not threatening, but can indicate a serious
pulmonary disease
Tuberculosis, lung abscess, cancer, pulmonary
infarction.

 If sputum is purulent------- infection of lung or airway is

indicated.
Cough that does not produce sputum is called a dry, or
nonproductive cough.
Acute cough is one that resolves in 2-3 weeks from onset
of illness or treatment of underlying condition.
Acute cough caused by upper respiratory tract (URT)
infections, allergic rhinitis, acute bronchitis, pneumonia,
congestive heart failure, pulmonary embolus, or
aspiration.

 A chronic cough is one that persists for more than

3 weeks.
In nonsmokers, almost always due to postnasal
drainage syndrome, asthma, or gastroesophageal
reflux disease
In smokers, chronic bronchitis is the most
common cause, although lung cancer should be
considered.

3- Cyanosis
When blood contains a large amount of unoxygenated
hemoglobin, it has a dark red-blue color which gives skin a
characteristic bluish appearance.
Most cases arise as a result of peripheral vasoconstriction
result is reduced blood flow, which allows hemoglobin to give
up more of its oxygen to tissues- peripheral cyanosis.
Best seen in nail beds
Due to cold environment, anxiety, etc.

 Central cyanosis can be due to :

Abnormalities of the respiratory membrane
Mismatch between air flow and blood flow
Expressed as a ratio of change in ventilation (V) to
perfusion (Q) : V/Q ratio
Pulmonary thromboembolus ---- reduced blood
flow
Airway obstruction ---- reduced ventilation
In persons with dark skin can be seen in the whites of the
eyes and mucous membranes.

 Lack of cyanosis does not mean oxygenation is normal!!

In adults not evident until severe hypoxemia is
present
Clinically observable when reduced hemoglobin
levels reach 5 g/ dl.
Severe anemia and carbon monoxide poisoning give
inadequate oxygenation of tissues without cyanosis
Individuals with polycythemia may have cyanosis
when oxygenation is adequate.

4- Pain
Originates in pleurae, airways or chest wall
Inflammation of the parietal pleura causes sharp or
stabbing pain when pleura stretches during inspiration
Usually localized to an area of the chest wall, where a
pleural friction rub can be heard
Laughing or coughing makes pain worse
Common with pulmonary infarction due to embolism

 Inflammation of trachea or bronchi produce a

central chest pain that is pronounced after
coughing
Must be differentiated from cardiac pain

High blood pressure in the pulmonary circulation

can cause pain during exercise that often
mistaken for cardiac pain (angina pectoris).

5- Clubbing
The selective bulbous enlargement of the end of a digit
(finger or toe).
Usually painless
Commonly associated with diseases
that cause decreased oxygenation
Lung cancer
Cystic fibrosis
Lung abscess
Congenital heart disease

Infectious Diseases of
The Lungs

Introduction:
Daily 10,000 liters of air - filtered..!
Pneumonia: Inflammation of lung.
Respiratory tract infections commonest in medical
practice.
Enormous morbidity & mortality.

Etiology:
Decreased general resistance
Virulent infection - Lobar pneumonia
Clearing mechanism
Decreased Cough Reflex
Injury of the cilia and mucosa
Low alveolar defense
Pulmonary edema or congestion
Obstructions
Retention of secretions

Types:
Viral
Bacterial
Mycoplasm
al
Fungal

Patterns of infections:
Airway - Bronchitis, Bronchiectasis
Parenchyma
Pneumonia
Bronchopneumonia
Lobar pneumonia
Lung abscess
Tuberculosis

Pneumonia
Pathology:
Alveolar
Bronchopneumonia (Streptococcus pneumoniae, Haemophilus
influenza, Staphylococcus aureus)
Lobar (Streptococcus pneumoniae)

Interstitial (Influenza virus, Mycoplasma pneumoniae)

Pathogenesis
Inhalation of air droplets
Aspiration of infected secretions or objects
Hematogenous spread

Bronchopneumonia
Suppurative inflammation of lung tissue caused by
Staph, Strep, Pneumo & H. influenza
Patchy consolidation not limited to lobes.
Usually bilateral
Lower lobes common, but can occur anywhere
Complications:
Abscess
Empyema
Dissemination

Bronchopneumonia

Bronchopneumonia

Bronchopneumonia

Bronchopneumonia:

Bronchopneumonia

Lobar Pneumonia:
Fibrinosuppurative consolidation whole lobe
Rare due to antibiotic treatment.
~95% - Strep pneumoniae
The course runs in four stages:
Congestion.
Red Hepatization.
Gray Hepatizaiton.
Resolution.

Lobar pneumonia:
whole lobe(s) involved
Fixed specimen, grey
hepatization

Lobar pneumonia

Lobar
Pneumonia:

Lobar Pneumonia Gray hep

Lung Abscess:
Focal suppuration with necrosis of lung tissue
Organisms commonly cultured:

Staphylococci
Streptococci
Gram-negative
Anaerobes
Frequent mixed infections

Mechanism:
Aspiration
Post pneumonic
Septic embolism
Neoplasms

Productive Cough, fever.

Clubbing

Complications: Systemic spread, septicemia.

Lung Abscess:

Abscess formation

Bronchopneumonia - Abscess
formation

Lung Abscess:

Pulmonary tuberculosis
Caused by Mycobacterium tuberculosis.
Transmitted through inhalation of infected droplets
Primary
Single granuloma within parenchyma and hilar
lymph nodes (Ghon complex).
Infection does not progress (most common).
Progressive primary pneumonia
Miliary dissemination (blood stream).

Ghon complex

Pulmonary tuberculosis
Secondary
Infection (mostly through reactivation) in a
previously sensitized individual.
Pathology
Cavitary fibrocaseous lesions
Bronchopneumonia
Miliary TB

Fibrocaseous

Granuloma

Miliary TB

Opportunistic pneumonias
Infections that affect immunosuppressed patients
Associated disorders:
AIDS
Iatrogenic
Cancer patients
Transplant recipients

Usual interstitial pneumonia / idiopathic

pulmonary fibrosis
Progressive fibrosing disorder of unknown cause
Adults 30 to 50 years old
Respiratory and heart failure (cor pulmonale) ~ 5 y