OBSTRUCTIVE LUNG DISEASE

Introduction

Obstructive lung disease (OLD) is a chronic respiratory condition characterized by the narrowing of the
airways, which makes it difficult for air to flow in and out of the lungs. This condition affects millions of
people worldwide and is a leading cause of morbidity and mortality. Understanding the physiology of
OLD is essential for the diagnosis, treatment, and management of this condition.

The respiratory system is responsible for bringing in oxygen and expelling carbon dioxide from the body.
The airways, which include the trachea, bronchi, and bronchioles, carry air to and from the lungs. The
lungs are composed of millions of small air sacs called alveoli, where gas exchange occurs. The process
of breathing is a complex interplay of muscles, nerves, and tissues that work together to maintain
proper lung function.

In normal lung function, air flows freely in and out of the lungs. However, in OLD, the airways become
narrowed, leading to difficulty in breathing. OLD can be caused by a variety of factors, including chronic
obstructive pulmonary disease (COPD), asthma, bronchiectasis, and cystic fibrosis.

COPD is a chronic lung disease characterized by the narrowing of the airways and damage to the lung
tissue. It is typically caused by smoking, but exposure to air pollution, secondhand smoke, and
occupational dust and chemicals can also contribute to the development of COPD. In COPD, the airways
become inflamed and narrowed, making it difficult for air to flow in and out of the lungs. The damage to
the lung tissue causes the alveoli to lose their elasticity, making it difficult for the lungs to expand and
contract properly.

Asthma is another common form of OLD. It is a chronic disease that causes inflammation and narrowing
of the airways. Asthma can be triggered by a variety of factors, including allergens, exercise, and viral
infections. In asthma, the airways become inflamed and produce excess mucus, which makes it difficult
for air to flow in and out of the lungs. The muscles around the airways can also become tight, further
narrowing the airways and making breathing even more difficult.

Bronchiectasis is a condition in which the airways become permanently widened and thickened. This can
be caused by infection, inflammation, or other conditions that damage the airways. In bronchiectasis,
the airways become less efficient at clearing mucus, leading to an increased risk of infection and further
damage to the lungs.

Cystic fibrosis is a genetic disorder that affects the lungs, pancreas, and other organs. It is caused by a
defect in the CFTR gene, which produces a protein that regulates the movement of salt and water in and
out of the cells. In cystic fibrosis, the mucus in the lungs becomes thick and sticky, making it difficult to
clear. This leads to recurrent infections and damage to the lung tissue.

The physiology of OLD involves a complex interplay of factors that contribute to the narrowing of the
airways. Inflammation is a key factor in the development of OLD, as it causes the airways to become
swollen and narrow. Inflammatory cells produce cytokines and other mediators that can further
exacerbate the inflammation and damage to the airways.

Smooth muscle contraction is another important factor in the development of OLD. The muscles around
the airways can become hyperactive and contract excessively, leading to further narrowing of the
airways. This can be triggered by a variety of factors, including allergens, irritants, and stress.

Mucus production is another important factor in the development of OLD. Inflammatory cells produce
excess mucus, which can accumulate in the airways and further narrow the airways. In addition, the
mucus can become thick and difficult to clear, leading to an increased risk of infection and further
damage to the lungs.

Finally, oxidative stress is another important factor in the development of OLD. Reactive oxygen species
(ROS) can damage the cells lining the airways, leading to further inflammation and damage

EPHYSEMA

Emphysema is a chronic pulmonary disease characterized by the destruction of the alveoli in the lungs. It
is one of the most common forms of chronic obstructive pulmonary disease (COPD), which also includes
chronic bronchitis and asthma. Emphysema is considered a progressive disease, meaning that it worsens
over time, and it is often caused by exposure to cigarette smoke or other irritants.

Emphysema affects the alveoli, which are the small sacs in the lungs where oxygen and carbon dioxide
are exchanged between the lungs and the bloodstream. In emphysema, the walls of the alveoli become
damaged and lose their elasticity. This results in the destruction of the alveolar structure and reduced
surface area for gas exchange. As a result, emphysema can cause difficulty breathing, coughing,
wheezing, and shortness of breath.

Causes of Emphysema

The primary cause of emphysema is cigarette smoking, which exposes the lungs to harmful chemicals
and irritants that can damage the alveoli. However, other factors can also contribute to the
development of emphysema. These include:

- Exposure to air pollution, including industrial pollutants, smog, and secondhand smoke

- Occupational exposure to dust and chemicals, such as coal dust, silica, and asbestos

- Genetic factors that predispose individuals to emphysema

Pathophysiology of Emphysema
The pathophysiology of emphysema involves a complex interplay of cellular and molecular processes.
The primary mechanism of emphysema is the destruction of the alveolar structure, which is caused by
several factors:

1. Oxidative stress: Cigarette smoke and other irritants can cause oxidative stress in the lungs. This leads
to the production of reactive oxygen species (ROS), which can damage the alveolar structure.

2. Inflammation: Irritants can also cause an inflammatory response in the lungs. This results in the
recruitment of immune cells, such as neutrophils and macrophages, which release enzymes that can
destroy the alveolar structure.

3. Protease-antiprotease imbalance: Proteases are enzymes that break down proteins, and
antiproteases are enzymes that inhibit the activity of proteases. In emphysema, there is a shift in the
balance between proteases and antiproteases, which can lead to the destruction of the alveolar
structure.

The physiologic effects of chronic emphysema are extremely varied, depending on the severity of the
disease and the relative degrees of bronchiolar obstruction versus lung parenchymal destruction.Among
the different abnormalities are the following:

1. The bronchiolar obstruction increases airway resistance and results in greatly increased work of
breathing. It is especially difficult for the person to move air through the bronchioles during expiration
because the compressive force on the outside of the lung not only compresses the alveoli but also
compresses the bronchioles, which further increases their resistance during expiration.

2. The marked loss of alveolar walls greatly decreases the diffusing capacity of the lung, which reduces
the ability of the lungs to oxygenate the blood and remove carbon dioxide from the blood.

3. The obstructive process is frequently much worse in some parts of the lungs than in other parts, so
that some portions of the lungs are well ventilated, while other portions are poorly ventilated. This often
causes extremely abnormal ventilation-perfusion ratios, with a very low

Va/Q. in some parts (physiologic shunt), resulting in poor aeration of the blood, and very high Va/Q. in
other parts (physiologic dead space), resulting in wasted ventilation, both effects occurring in the same
lungs.

4. Loss of large portions of the alveolar walls also decreases the number of pulmonary capillaries
through which blood can pass. As a result, the pulmonary vascular resistance often increases markedly,
causing pulmonary hypertension3

Symptoms of Emphysema

The symptoms of emphysema can vary depending on the severity of the disease. Early symptoms may
include:

- Shortness of breath, especially during physical activity

- Wheezing

- Coughing, with or without mucus production

As the disease progresses, symptoms may include:

- Difficulty breathing, even when at rest

- Fatigue

- Unintentional weight loss

- Bluish tint to the lips or fingernail beds (cyanosis)

Diagnosis of Emphysema

Emphysema is typically diagnosed using a combination of medical history, physical examination, and
diagnostic tests. Your doctor may ask about your smoking history, exposure to irritants, and any
symptoms you may be experiencing. They may also perform a physical examination, including listening
to your lungs with a stethoscope.

Diagnostic tests that may be used to diagnose emphysema include:

- Pulmonary function tests: These tests measure how well your lungs function by measuring the amount
of air you can inhale and exhale, how quickly you can exhale, and how much air remains in your lungs
after exhaling.

- Chest X-ray or CT

Treatment:

There is no cure for emphysema, but there are treatments available to help manage symptoms and slow
the progression of the disease. The most important step in preventing emphysema is to quit smoking, as
this is the most common cause of the disease. Other treatments may include medications to help
manage symptoms, oxygen therapy to help with breathing, and pulmonary rehabilitation programs to
help improve lung function and overall health.

Prevention:

The best way to prevent emphysema is to avoid exposure to the risk factors that can cause the disease.
This includes quitting smoking, avoiding exposure to air pollution, and minimizing exposure to
occupational hazards such as dust and chemicals. Regular exercise and a healthy diet can also help to
improve lung function and overall health.

Chronic Bronchitis
 What is chronic bronchitis?

Chronic bronchitis is diagnosed on clinical grounds: it is defined by the presence of a persistent

productive cough for at least 3 consecutive months in at least 2 consecutive years.5

Chronic bronchitis is a type of COPD (chronic obstructive pulmonary disease). COPD is a group of lung
diseases that make it hard to breathe and get worse over time.

Chronic bronchitis is inflammation (swelling) and irritation of the bronchial tubes. These tubes are the
airways that carry air to and from the air sacs in your lungs. The irritation of the tubes causes mucus to
build up. This mucus and the swelling of the tubes make it harder for your lungs to move oxygen in and
carbon dioxide out of your body.

What causes chronic bronchitis?

The cause of chronic bronchitis is usually long-term exposure to irritants that damage your lungs and
airways. In the United States, cigarette smoke is the main cause. Pipe, cigar, and other types of tobacco
smoke can also cause chronic bronchitis, especially if you inhale them.

Exposure to other inhaled irritants can contribute to chronic bronchitis. These include secondhand
smoke, air pollution, and chemical fumes or dusts from the environment or workplace.

Rarely, a genetic condition called alpha-1 antitrypsin deficiency can play a role in causing chronic
bronchitis.

Pathophysiology
Chronic bronchitis is thought to be caused by overproduction and hypersecretion of mucus by goblet
cells. Epithelial cells lining the airway response to toxic, infectious stimuli by releasing inflammatory
mediators and eg pro-inflammatory cytokines. During an acute exacerbation of chronic bronchitis, the
bronchial mucous membrane becomes hyperemic and edematous with diminished bronchial
mucociliary function. This, in turn, leads to airflow impediment because of luminal obstruction to small
airways. The airways become clogged by debris and this further increases the irritation. The
characteristic cough of bronchitis is caused by the copious secretion of mucus in chronic bronchitis.

Who is at risk for chronic bronchitis?

The risk factors for chronic bronchitis include:

Up to 75% of people who have chronic bronchitis smoke or used to smoke.

Long-term exposure to other lung irritants, such as secondhand smoke, air pollution, and
chemical fumes and dusts from the environment or workplace.

Age. Most people who have chronic bronchitis are at least 40 years old when their symptoms
begin.
 Genetics. This includes alpha-1 antitrypsin deficiency, which is a genetic condition. Also, smokers
who get chronic bronchitis are more likely to get it if they have a family history of COPD.

What are the symptoms of chronic bronchitis?

Frequent coughing or a cough that produces a lot mucus

Wheezing

A whistling or squeaky sound when you breathe

.Shortness of breath, especially with physical activity

.Tightness in your chest

hypoxemia6,cyanosis6and hypercapnia6.

Bronchiectasis

Defined as permanent abnormal dilatation of bronchi and bronchioles usually associated with chronic
necrotizing infection.

Dilation is caused by destruction of smooth muscle and the supporting elastic tissue
Patients present with cough, fever, and expectoration of copious amounts of foul-smelling, purulent
sputum.

The dilatation should be permanent to be considered bronchiectasis. (Reversible bronchial dilatation is

often found with viral and bacterial pneumonia.)
Bronchiectasis can be divided into the following categories:
& Cylindroid bronchiectasis
& Fusiform bronchiectasis
& Saccular bronchiectasis

The most frequent causes of bronchiectasis include:

Localized obstruction of bronchus by tumor, foreign bodies, and mucous impaction
Diffuse obstructive airway diseases such as asthma and chronic bronchitis
Congenital and hereditary conditions such as cystic fibrosis, immunodeficiency states ,immotile
cilia syndrome, and Kartagener syndrome
Necrotizing pneumonia caused by Mycobacterium tuberculosis, staphylococci, and mixed
infections.
Pathophysiology of bronchiectasis
Two processes contribute to bronchiectasis : obstruction and chronic infection.
For example, obstruction caused by a foreign body impairs clearance of secretions, providing a favorable
substrate for superimposed infections.
The resultant inflammatory damage to the bronchial wall and the accumulating exudate further distend
the airways, leading to irreversible dilation.
Conversely, a persistent necrotizing infection in the bronchi or bronchioles may lead to poor clearance of
secretions, obstruction, and inflammation with peribronchial fibrosis and traction on the bronchi,
culminating again in full-blown bronchiectasis.
MORPHOLOGY
Bronchiectasis usually affects the lower lobes bilaterally, particularly those air passages that are most
vertical.
When caused by tumors or aspiration of foreign bodies, the involvement may be sharply localized to a
single segment of the lungs. Usually, the most severe involvement is found in the more distal bronchi and
bronchioles. The airways may be dilated to as much as four times their usual diameter and can be
seen on gross
examination almost out to the pleural surface. By contrast, in normal lungs, the bronchioles cannot be
followed by
eye beyond a point 2 to 3 cm from the pleura.
The histologic findings vary with the activity and chronicity of the disease. In full-blown active cases, an
intense acute and chronic inflammatory exudate within the walls of the bronchi and bronchioles leads to
desquamation of lining epithelium and extensive areas of ulceration. Typically, mixed flora are cultured
from the sputum. The usual organisms include staphylococci, streptococci, pneumococci, enteric
organisms, anaerobic and microaerophilic bacteria, and (particularly in children) Haemophilus influenzae
and Pseudomonas aeruginosa.
When healing occurs, the lining epithelium may regenerate completely; however, the injury usually
cannot be repaired and abnormal dilation and scarring persist. Fibrosis of the bronchial and bronchiolar
walls and
peribronchiolar fibrosis develop in more chronic cases. In some instances the necrosis destroys the
bronchial or bronchiolar walls, producing an abscess cavity.
Clinical Features of Bronchiectasis
Characterized by severe, persistent cough associated with expectoration of mucopurulent,
sometimes fetid, sputum.
Other common symptoms include:
dyspnea, rhinosinusitis, and hemoptysis.
Severe, widespread bronchiectasis may lead to significant obstructive ventilatory defects, with:
hypoxemia, hypercapnia, pulmonary hypertension, and cor pulmonale.

However, with current treatment outcomes have improved and severe complications of bronchiectasis,
such as brain abscess, amyloidosis, and cor pulmonale occur less frequently now than in the past.

Bronchiectasis

Bronchiectasis is a long-term lung condition in which one or more sections of the airways become
damaged and inflamed, causing them to become wider than normal. Extra mucus is produced, which
becomes difficult to clear so it collects in the widened parts of the airways.This build up of mucus in the
airways can become infected by bacteria. Bacterial infection can cause further damage to the airways,
which in turn causes more mucus to be produced that becomes more difficult to cough up. Once the
damage has occurred, it is permanent. Good control early on is important to prevent further damage.
What causes bronchiectasis?

In about half of all cases the cause is not found. This is known as idiopathic bronchiectasis. There are
some known causes including:

 severe lung infection, especially during childhood, such as pneumonia, whooping cough or measles;
underlying inherited disease, such as cystic fibrosis, where the mucus in the airways is too thick, or
primary ciliary dyskinesia, where the hairs lining the airways do not work properly; lack of immunity to
infection, i.e. a lack of disease-fighting cells called antibodies; severe allergic response to fungus
(moulds such as aspergillus), which is often associated with asthma; gastric reflux, when stomach acid
travelling up the food tube from the stomach is breathed in.

What are the symptoms of bronchiectasis?

The main symptoms of bronchiectasis are coughing up sputum (phlegm) and repeated chest infections.
The severity of symptoms varies depending on the severity of the disease.

 Mild disease - occasional cough producing small amounts of sputum and infrequent chest infections
(less than two per year). Sputum is usually clear or light in colour. Severe disease - coughing up large
amounts of sputum on most days and frequent chest infections. Sputum is usually dark yellow, green or
brown and bacteria are found in the sputum even when the person is well.How is bronchiectasis
diagnosed?

Getting a diagnosis of bronchiectasis is not always easy and can take some time. Symptoms can be
similar to other long-term lung conditions (such as COPD) and it can be difficult to distinguish between
the two. Additionally, some people have both bronchiectasis and COPD, making diagnosis and
management more difficult.

If your GP thinks that you might have bronchiectasis, they will arrange some tests for you. Depending on
the results of these, you may be referred to a specialist respiratory consultant.Tests your GP may
organise include:

 Chest X-ray to exclude any other conditions

 Sputum sample to see if there are any bacteria in your sputum

 Blood tests to look for possible causes of bronchiectasis

Tests your respiratory consultant may organise:

 High-resolution computed tomography (HRCT) scan - this is a special type of X-ray that uses
computers to make detailed images of your lungs to show if the airways inside your lungs are widened.
Widened airways on a CT scan usually confirm bronchiectasis. Lung function tests to see how well your
lungs are able to transfer air in and out. Various other tests to look for a possible cause of your
bronchiectasis. These may include bronchoscopy, further blood tests and sputum sampling.
How is bronchiectasis managed?

Usually, the damage to your airways that causes bronchiectasis can’t be reversed, so treatment is to
help prevent further damage, infections and reduce your symptoms. The cause of your bronchiectasis, if
it can be found out, should also be treated. If you get an infection, it is treated with antibiotics. Some
people who get a lot of infections take continuous antibiotics, either in tablet form or by inhaling them
through a nebuliser. It is important that you see your GP if you think you have a chest infection so it can
be treated quickly.Your doctor should refer you to a respiratory physiotherapist, who will teach you
various breathing exercises and techniques to help clear sputum from your lungs. It is essential that you
continue to do this yourself regularly.You may find your symptoms are reduced if you use an inhaler to
open up your airways. There are different types of inhalers, including bronchodilators and steroid
inhalers.Some people use treatments to help remove mucus from their airways; these are sometimes
called mucus clearance agents. They include hypertonic saline, a salt water solution that can be inhaled
into the lungs through a nebuliser and keeps the airways hydrated, and carbocisteine, which makes
mucus thinner and less sticky so it is easier to cough up.Very occasionally, in cases where bronchiectasis
occurs in a single section of the lung, the damaged areas can be removed with surgery. This is only
recommended in a very small number of cases when other treatments have not been successful.