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
Type I
pneumocyte
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
• Mycoplasmal
• 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
 Broncho-
pneumonia
 Broncho-
pneumonia
 Broncho-
pneumonia
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