Chapter 7Chapter 7Diseases of the Diseases of the

Respiratory SystemRespiratory System

Department Of PathologyDepartment Of PathologyGuangxi Medical UniversityGuangxi Medical University

Zili LvZili Lv吕自力吕自力

Anatomic Structures and Anatomic Structures and FunctionsFunctions

Bronchi

Bronchioles

Alveolar ducts

Alveoli

Clinical features of Clinical features of respiratory diseasesrespiratory diseases

•1. Cough:•2. Sputum Production 痰 : •3. Hemoptysis 咯血•4. Dyspnoea 呼吸困难 :•5. Cyanosis 苍白 :•6. Chest pain:

Contents Contents

•1. Acute infection of the lung •2. Chronic obstructive

pulmonary diseases & chronic cor pulmonale

•3. Chronic diffuse interstitial lung disease, carcinoma of nasopharynx and lung.

Acute infection

of the lung

Pneumonia

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Case 1 analysisCase 1 analysis

•History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

• T: 40℃, R: 32 times/min.

• Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.

• Blood examination: WBC: 13.5x 109/ L

Classification of pneumoniaClassification of pneumonia•Clinical circumstance Primary and Secondary•Etiological agent: Bacterial, Virus, Fungal•Host reaction Fibrinous & Suppurative•Anatomical pattern Lobar & Lobular

LOBAR PNEUMONIALOBAR PNEUMONIA

(( 一一 )) 大叶性肺炎大叶性肺炎p187p187

Lobar pneumoniaLobar pneumonia

• Affects a large part, or the entirety of a lobe

• Relatively uncommon in infancy and old age

• Affects males more than females• 90% due to pneumococcus• Cough and fever with purulent or

Rusty Sputum 铁锈色痰

A. EtiologyA. Etiology

Pathogen: Streptococcus pneumonia

肺炎球菌 III 型Infective Route: Inhalation, Aspiration 吸入 Risk Factors ： Cold, drunk, tired, diabetes

B. Pathology*B. Pathology*

• Acute exudative fibrinous inflammation

• Involves one whole lobe or

several lobes

• The bronchi are not involved

Pathologic FeaturesPathologic Features

•Acute congestion 充血水肿期•Red hepatization 红色肝样变期 •Gray hepatization 灰色肝样变期 •Resolution 溶解消散期

1. Stage of acute congestion1. Stage of acute congestion 1st-2nd day 1st-2nd day

•(1)Gross changes: Heavy, dark red and firm•(2)Microscopic changes:

•(3)Clinical features:

Stage of acute congestionStage of acute congestion

Alveolar capillaries: Dilated

Air space: fluid, RBC, WBC

•Fever, cough, cyanopathy ( 发绀 )

•Chest pain•Bacteremia •Bacteria can be found in sputum

Stage of acute congestionStage of acute congestionclinical featuresclinical features

2. Stage of Red Hepatization: 2. Stage of Red Hepatization:

2nd-4th day 2nd-4th day

• (1)Gross changes:

• (2)Microscopic changes:

• (3)X-ray

(4)Clinical features:

(1)Gross changes of red (1)Gross changes of red hepatizationhepatization

• Red and consolidation, just like liver

(2)Microscopic changes of (2)Microscopic changes of red hepatization red hepatization

•A. Capillaries congestion

•B. Exudation: Fibrin, large number of RBC •C. Fibrinous pleurisy

Microscopical changesMicroscopical changes

红色肝样变期红色肝样变期 XX 线特点线特点(3)

Chest x-ray

• The middle segment of right upper lobe become consolidated and show large-area uniform dense shadow.

(4) Clinical features of red (4) Clinical features of red hepatizationhepatization

•Fever, cough, chest pain•Rapid breathing, cyanopathy•Dullness 浊音 , vocal fremitus

enhancement 语颤增强•Rusty sputum 铁锈色痰

3. Stage of 3. Stage of graygray hepatization: hepatization: 5th-6th day 5th-6th day

• Gross changes:

• Microscopic changes:

• X-ray

Clinical features:

(1)Gross changes of (1)Gross changes of grey hepatization grey hepatization

•Dry •Gray •Firm •Consolidation

(2)Histological changes(2)Histological changes

• Capillary is not dilated anymore.

• Alveolar space is filled with neutrophil and fibrin

Histological changes of Histological changes of grey hepatizationgrey hepatization

X-ray features of gray X-ray features of gray hepatizationhepatization

• (3)Chest x-ray: high dense shadow can be found at the right upper lobe

(4)Clinical features of gray (4)Clinical features of gray hepatizationhepatization

• Consolidation: dullness, vocal fremitus enhancement

•Sputum: mucus purulent sputum

•Dyspnoea( 缺氧） : is not obvious

4. Stage of 4. Stage of ResolutionResolution 7 days later 7 days later

• Gross changes: Friable and mottled• Microscopic changes:• X-ray• Clinical features:

Microscope changes of Microscope changes of resolutionresolution

• The fibrin and cell debris are digested by enzymatic

• The exudation is remove

Pathologic FeaturesPathologic Features

LOBULAR PNEMONIALOBULAR PNEMONIA

(( 二二 )) 小叶性肺炎小叶性肺炎 (Bronchopneumonia)(Bronchopneumonia)

(( 支气管肺炎支气管肺炎 ))

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Lobular pneumoniaLobular pneumoniaBronchopneumoniaBronchopneumonia

• Bronchi are infected• Patchy consolidation• Centred on inflamed bronchioles or

bronchi• Secondary pneumonia• Less virulent agents, in infancy or

old age• Suppurative inflammation 化脓性炎

•Pathogen: many bacteria, • Infection via: Inhalation, Aspiration•Risk Factors: secondary

A. Etiology

B. PathologyBronchopneumonia ， Gross

Lower lobes, dorsal side

双肺下叶 , 背侧

Multiple firm areas, around inflamed bronchioles.多个实变病灶 , 围绕细支气管

B. Pathology B. Pathology Bronchoneumonia, Bronchoneumonia,

Microscope:Microscope:

1. Multiple lesionsPurulent bronchitis and bronchiolitis

( 化脓性细支气管炎 )

2. Alveolar spaces surrounding the lesions are filled with neutrophil

3. Compensatory emphysema ( 代偿性肺气肿 )

C. Clinical FeaturesC. Clinical Features

•The onset is insidious, nonspecific

• low-grade fever•Dyspnea is not prominent•The typical feature is Purulent Sputum 脓痰

• Chest x-ray

• Several scattered patchy shadows evidently in bilateral lower lobes

Lobar pneumonia

Lobular pneumonia

Air space pneumonia

Complications

Resolution

Complications of acute air Complications of acute air space pneumoniaspace pneumonia

• Pleura involvement• Bacteremia• Suppuration (Abscess Formation)• Necrotizing bacterial pneumonia• Pulmonay carnification 肺肉质变

• Lung abscess

• Pulmonary carnification

Distribution

Number

Host reaction

Clinical features

What are the What are the differences?differences?

Acute interstitial pneumoniaAcute interstitial pneumonia间质性肺炎间质性肺炎

• 1. Agents: Virus (SARS, Avian influenza) Mycoplasma or Pneumocystis• 2. Interstitium• 3. Atypical pneumonia• 4. Infiltration with lymphocyte,

monocyte

Viral pneumoniaViral pneumoniapathologic featurespathologic features

• The alveolar septa are expanded• Cell infiltrate: lymphocyte, plasma

cells• Air spaces are air filled• Epithelial necrosis• Inclusion bodies 病毒包涵体• Multinucleated giant cells 多核巨细胞• Hyaline membranes 透明膜

Viral Pneumonia

• Severe Acute Respiratory Syndrom (SARS) 重症急性呼吸综合征

• Atypical pneumonia （非典型肺炎）• Cornonavirus 变异的冠状病毒• Extensive consolidation, hyaline

membrane, necrosis, pulmonary fibrosis

• Die in respiratory distress

SARSSARS

Clinical featuresClinical features

Electro microscopeElectro microscope

Avian Influenza 禽流感

人畜共患传染病

H5N1

Interstitial

Atypical

Bird fluBird flu

• An infection disease of birds • 1997, Hong Kong, outbreak• Vascular disturbances• Fever, cough• All the other organs can be

affected, for example, liver, heart and kidney.

Interstitial pneumonia•Atypical pneumonia •Congested, edematous, mononuclear cells infiltration

Mycoplasma pneumonia 支原体肺炎

Air space

pneumonia

Lobar pneumonia

Lobular pneumonia

Interstitial

pneumonia

Viral pneumonia

Mycoplasma pneumonia

ARDSARDSAcute Respiratory Acute Respiratory Distress SyndromeDistress Syndrome

• An acute diffuse alveolar injury• Terminal events in many of the

patients• Serious ill, the mortality rate > 50%• Results from ischemic, endotoxins,

enzymes.

Case 1 analysisCase 1 analysis

•History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

• T: 40℃, R: 32 times/min.

• Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.

• Blood examination: WBC: 13.5x 109/ L

Questions Questions

•What does this patient should be diagnosed as?

•Which type of inflammation?•Why does the patient cough

with the “rusty” sputum?

• Half a year later, this student was enrolled to the army.

• The chest x-ray indicated there was a nodule in his left lung.

• The nodule was checked under microscope, there was much granulation tissue in the alveolar spaces.

•WHY?

Case abstract 2Case abstract 2

•Male, 70-year-old, he had suffered hypertensive heart disease and left heart failure for half a year, and cough and expectoration for 1 year. These symptoms aggravated 4 days ago with fever and purulent sputum.

•T: 38℃, HR: 112 times/min, R: 35 times/min, BP: 22.6/13.5 kPa.

•Blood WBC: 10.2 X 109/L

•X-ray: Several scattered patchy shadows evidently in bilateral lower lobes.

Questions Questions

•What does this patient will be diagnosed as?

•Which type of inflammation?•Why do patients cough with

the purulent sputum?

Summary Summary

•How to differentiate the lobar pneumonia and the bronchopneumonia?

•What is the “rusty sputum”?