The theme of the The theme of the lecturelecture: : ““Bronchial Bronchial asthma. Chronic asthma. Chronic

obstructive obstructive pulmonary disease. pulmonary disease.

The syndrome of The syndrome of hyperinflation of hyperinflation of

lungs. Pulmonary lungs. Pulmonary emphysemaemphysema""

Ass-prof.N.BilkevychAss-prof.N.Bilkevych

The syndrome of bronchial The syndrome of bronchial obstructionobstruction

Obstructio (lat.) – barrier, obstracle.Obstructio (lat.) – barrier, obstracle. Causes of bronchial obstruction:Causes of bronchial obstruction:

- accumulation of fluid in fine bronchi;- accumulation of fluid in fine bronchi; - edema of bronchial mucosa;- edema of bronchial mucosa; - spasm of bronchial smooth muscles;- spasm of bronchial smooth muscles; - poor elasticity of lungs.- poor elasticity of lungs.

Pulmonary emphysemaPulmonary emphysema

Respiratory system anatomyRespiratory system anatomy

Bronchial obstruction may be:Bronchial obstruction may be:

Transient:Transient: - bronchial asthma,- bronchial asthma, - pneumonia.- pneumonia.

Permanent:Permanent: - chronic obstructive bronchitis,- chronic obstructive bronchitis, Pulmonary emphysema.Pulmonary emphysema.

Bronchial asthmaBronchial asthma

Asthma is a bronchial hypersensitivity disorder Asthma is a bronchial hypersensitivity disorder characterized by reversible airway obstruction, produced characterized by reversible airway obstruction, produced by a combination of mucosal edema, constriction of the by a combination of mucosal edema, constriction of the bronchial musculature, and excessive secretion of viscid bronchial musculature, and excessive secretion of viscid mucus, causing mucous plugs.mucus, causing mucous plugs.

Essentials of Diagnosis:Essentials of Diagnosis:• • Recurrent acute attacks of dyspnea, cough, and mucoid Recurrent acute attacks of dyspnea, cough, and mucoid

sputum, usually accompanied by wheezing.sputum, usually accompanied by wheezing.• • Prolonged expiration with generalized wheezing and Prolonged expiration with generalized wheezing and

musical rales.musical rales.• • Bronchial obstruction reversible by drugsBronchial obstruction reversible by drugs

EthiologyEthiology 40-80 % 40-80 % of patients has heredital predispositionof patients has heredital predisposition Acquired ethiological factorsAcquired ethiological factors Domestic allergensDomestic allergens ( ( dustdust, , insect allergensinsect allergens, , fungifungi, , animal wool, epidermisanimal wool, epidermis)) Environmental allergensEnvironmental allergens ( ( fungifungi, , insect allergensinsect allergens, , pollen etcpollen etc)) Food allergyFood allergy ( ( milkmilk, , flourflour, , fishfish, , chemical admixtures to foodchemical admixtures to food)) drugsdrugs ( ( antibioticsantibiotics, , enzymesenzymes, , aspirinaspirin)) bacterial allergensbacterial allergens ( ( neisserianeisseria, , Staphylococcus aureusStaphylococcus aureus, , Candida albicansCandida albicans, ,

mycoplasmamycoplasma, , helmintshelmints))

PathogenesisPathogenesis Bronchial asthma is a complex inflammatory condition Bronchial asthma is a complex inflammatory condition

involving many inflammatory cells, which release a wide involving many inflammatory cells, which release a wide variety of mediators. These mediators act on cells of the variety of mediators. These mediators act on cells of the airway leading to smoothairway leading to smoothmuscle contraction, mucus hypersecretion, plasma muscle contraction, mucus hypersecretion, plasma leakage, oedema, activation of cholinergic reflexes and leakage, oedema, activation of cholinergic reflexes and activation of sensory nerves, which can lead to activation of sensory nerves, which can lead to amplifiaction of the ongoing inflammatory response. amplifiaction of the ongoing inflammatory response. Chronic inflammation also leads to structural changes, Chronic inflammation also leads to structural changes, such as subepithelial fibrosis and smooth muscle such as subepithelial fibrosis and smooth muscle hypertrophy and hyperplasia, which are less easy to hypertrophy and hyperplasia, which are less easy to reverse than acute processes. Inadequately treated reverse than acute processes. Inadequately treated chronic asthma is thus associated with structural chronic asthma is thus associated with structural changes in the lungschanges in the lungs

Сlassification of bronchial asthma

Degree of severity Course

І

ІІ

ІІІ

ІV

Intermittent course

Persistent course

mild

moderate

severe

Intermittent asthma

Attacks are short and mild

day <1 time a weak

night ≤2 times a month

Between attacks symptoms are abcent

Persisting asthma

mild

Symptoms are permanent but short

day <1 time a weal but not more than 1 time a

day

night =1-2 times a month

moderate

Symptoms are premanent

day permanently

night > 1 time a weak

Limitation of physical activity

Night is deranged

severe

day

night

Permanent long attacks

Limitation of physical activity

Exacerbations may be dangerous for patient’s life

Diagnosis: Intermittent bronchial asthma, m,ild degree of

exacerbation, respiratory insufficiency 0 degree.

Immunological mechanismsImmunological mechanismsCaused byCaused by::ІІgg Е Еbasophilsbasophilsmast cellsmast cells MediatorsMediators::histaminehistamineprostaglandinesprostaglandinesleukotriensleukotriens

Non-immunologacal mechanisms

1. Pseudoallergic

drugs

food products

Plant of animal allergens

Excretion of bioactive

substances and

activation of

complement

Bronchial obstruction in bronchial Bronchial obstruction in bronchial asthma is caused by:asthma is caused by: spasm of bronchial smooth spasm of bronchial smooth

muscles;muscles; swelling of bronchial mucosa;swelling of bronchial mucosa; Hypersecretion of teniacious Hypersecretion of teniacious

mucoid sputum.mucoid sputum.

Clinical FindingsClinical Findings

Asthma is characterized by recurrent attacks of dyspnea, Asthma is characterized by recurrent attacks of dyspnea, cough, and expectoration of tenacious mucoid sputum, cough, and expectoration of tenacious mucoid sputum, and usually wheezing. Symptoms may be mild and may and usually wheezing. Symptoms may be mild and may occur only in association with respiratory infection, or occur only in association with respiratory infection, or they may occur in various degrees of severity to the they may occur in various degrees of severity to the point of being life-threatening. point of being life-threatening.

Classic allergic (atopic) asthma usually begins in childhood Classic allergic (atopic) asthma usually begins in childhood and becomes progressively more severe throughout life, and becomes progressively more severe throughout life, although spontaneous remissions may occur in although spontaneous remissions may occur in adulthood. Hay fever often accompanies atopic asthma.adulthood. Hay fever often accompanies atopic asthma.

The The acute attackacute attack is characterized by is characterized by dyspnea usually associated with expiratory dyspnea usually associated with expiratory wheezing that may be heard without a wheezing that may be heard without a stethoscope. Cough may be present but is stethoscope. Cough may be present but is usually not the predominant symptom. usually not the predominant symptom. There is a small group of patients with There is a small group of patients with asthma in whom paroxysmal cough may asthma in whom paroxysmal cough may be the predominant symptom.be the predominant symptom.

Clinical patternClinical pattern

Inspection

Forsed position of a patient – orthopnoe

Skin is pale cyanotic

Respiration later (10-12 per min)

Wheezes

Swelling of neck veins

Mouth is opened

Viscous white transparent sputum

Inspection of a chest

Inspiratory position

Participation of additional respiratory muscles in respiration

palpation

Intercostal spaces are wide

Vocal fremitus is weakened

The chest is rigid

Percussion

Bundbox sound

Upper and lower borders of the lungs are diaplaced upward and

downward

Respiratory mobility of lungs lower borders is markedly limited

Appearance of a patient during attack of Appearance of a patient during attack of asthmaasthma

Auscultation (before expectoration of sputum)

Weakened vesicular breathing

Prolonged expiration

Dry whistling (high-pitched) rales

Auscultation (during expectoration of sputum)

Amount of high-pitched rales decreases

Amount of low-pitched rales increases

Appearance of moist rales

Complications

Hypoxaemic coma

1. Status asthmaticus acute right ventricular failure

Cardiopulmonic shock

2. Acute pulmonary emphysema

3. Pneumothorax

4. Rib fracture

5. Athelectasis

6. Asthmatic encefalopathy

7. Decompensation of chronic right ventricular failure

Status asthmaticus Status asthmaticus

This is a complication of asthma.This is a complication of asthma. When asthma becomes prolonged, with When asthma becomes prolonged, with

severe intractable wheezing, it is known as severe intractable wheezing, it is known as status asthmaticus.status asthmaticus.

Status asthmaticus is attack af asthma Status asthmaticus is attack af asthma which lasts for more than 24 hours. which lasts for more than 24 hours. Patients are not sensitive to Patients are not sensitive to ββ-agonists. -agonists. Corticosteroids are used for treatment.Corticosteroids are used for treatment.

Laboratory diagnostics during attack

Blood:

Moderate lymphocytosis

eosinopenia

Sputum:

eosinophils

Charkot-Leyden crystals

Kurshmann’s spirals

Instrumental diagnostics

Investigation of external respiratory function

І. Spyrography

FEV1 < 80% Tiffneu index ( FVLC1 /VLC, %)

ІІ. Pneumotachymetry

Of expiratory force

ІІІ. Peak -fluometry (analysis of peak volumetric velocity of forced expiration)

Chext x-ray

X-ray hypertranslucencv of lung fields.

Widened intercostal spaces

Low fiat diaphragm

Increased retrosternal translucency

Narxow vertical heart

Large hilar shadows

Diminished peripheral vascular pattern

Дослідження харкотинняДослідження харкотиння

спірограмаспірограма

Chest X-ray in asthmaChest X-ray in asthma

X-ray shows pulmonary emphysemaX-ray shows pulmonary emphysema

Endoscopic findings: hyperemia, edema of Endoscopic findings: hyperemia, edema of bronchial mucosa, hypersecretionbronchial mucosa, hypersecretion

Allergic tests allow to determine Allergic tests allow to determine allergensallergens

Positive reactionPositive reaction

Principles of treatment

І. Ethiologic

ІІ. Pathogenetic

1. Ethiologic

2. Elimination of allergens

Pathogenetic

1. Influence on immunological stage

Specific hyposensibilization

Nonspecific hyposensibilization

- Diet

- Histaglobuline

Corticosteroids

Immunomodulation

2. Influence on pathochemical stage

Mast cells stabilizatirs

Leukotriens inhibitors

Proteolytic enzymes inhibitors

Antioxidants

3. Influence on pathophysiological stage

bronchodilators

- β-agonists

- М-cholinolitics

- Са++-channel antagonists

- Spasmolitics

Expectorants

Physiotherapy

Usage of inhalerUsage of inhaler

SolotvinoSolotvino ( (salt cavessalt caves))

SolotvinoSolotvino ( (salt cavessalt caves))

SolotvinoSolotvino ( (salt cavessalt caves))

PhysiotherapyPhysiotherapy

ClimatotherapyClimatotherapy

Elimination of risk-factorsElimination of risk-factors

Bronchoscopy is used if it is necessaryBronchoscopy is used if it is necessary

Chronic obstructive pulmonary Chronic obstructive pulmonary disease (COPDdisease (COPD))

The common combination of chronic bronchitis and emphysema has also been The common combination of chronic bronchitis and emphysema has also been termed chronic obstructive airways disease (COAD) or chronic obstructive termed chronic obstructive airways disease (COAD) or chronic obstructive pulmonary disease (COPD). pulmonary disease (COPD).

This is a morbid condition characterized by non-reverseble bronchial obstruction This is a morbid condition characterized by non-reverseble bronchial obstruction caused by deformation and sclerosis of bronchial tree due to persistent caused by deformation and sclerosis of bronchial tree due to persistent inflammation.inflammation.

Up to 20% of adults worldwide have the disease, and this proportion is higher in Up to 20% of adults worldwide have the disease, and this proportion is higher in heavily industrialized countries. Chronic bronchitis occurs in the majority of heavily industrialized countries. Chronic bronchitis occurs in the majority of heavy smokers, but significant airway obstruction or emphysema, or both occurs heavy smokers, but significant airway obstruction or emphysema, or both occurs in only a minority.in only a minority.

It is the third most common cause of death in men over 65 years (60 per It is the third most common cause of death in men over 65 years (60 per 100.000), and is more common in men (8%) than women (3%). COPD develops 100.000), and is more common in men (8%) than women (3%). COPD develops in at least 80% of smokers.in at least 80% of smokers.

Chronic bronchitisChronic bronchitis

This is a clinical syndrome in which there is excess This is a clinical syndrome in which there is excess mucous secretion by bronchial gob let cells.mucous secretion by bronchial gob let cells.

This stimulates the cough so that sputum is produced This stimulates the cough so that sputum is produced daily for at least 3 months of the year. There aredaily for at least 3 months of the year. There are often often episodes of superimposed viral or bacterial infection in episodes of superimposed viral or bacterial infection in which the sputum may be yellow or green and often which the sputum may be yellow or green and often contains a fleck of blood. Many patients also have an contains a fleck of blood. Many patients also have an intermittent wheeze with objective evident: of airways intermittent wheeze with objective evident: of airways obstruction on pulmonary function tests am some may obstruction on pulmonary function tests am some may have acute severe bronchoconstriction ii response to have acute severe bronchoconstriction ii response to respiratory infections or to irritants or allergens respiratory infections or to irritants or allergens (asthmatic bronchitis).(asthmatic bronchitis).

EmphysemaEmphysema This is a syndrome which include symptoms of lung overfilling with air (air This is a syndrome which include symptoms of lung overfilling with air (air

hyperinflation). hyperinflation). Emphysema is characterized by enlargement of the airspaces distal to the Emphysema is characterized by enlargement of the airspaces distal to the

terminal bronchioles, either from dilatation or destruction of their walls.terminal bronchioles, either from dilatation or destruction of their walls. It is a pathological or radiological rather than a clinical diagnosis and is It is a pathological or radiological rather than a clinical diagnosis and is

commonly associated with chronic bronchitis.commonly associated with chronic bronchitis. Destruction of the alveolar septae results in the formation of multiple bullae in Destruction of the alveolar septae results in the formation of multiple bullae in

the lungs, with hyperinflation of the chest and impaired respiratory function. the lungs, with hyperinflation of the chest and impaired respiratory function. The PA chest X-ray usually shows hyperinflation of both lung fields, producing The PA chest X-ray usually shows hyperinflation of both lung fields, producing

depression of both diaphragms and a characteristic long, thin mediastinum. At depression of both diaphragms and a characteristic long, thin mediastinum. At the right lateral chest X-ray may show a marked increase in the posteroanterior the right lateral chest X-ray may show a marked increase in the posteroanterior diameter of the chest.diameter of the chest.

CT scan may demonstrate bullous areas and reduced density of the lung CT scan may demonstrate bullous areas and reduced density of the lung structure on thin slices of lung. The measurements of lung dencity correlate well structure on thin slices of lung. The measurements of lung dencity correlate well with histological findings.with histological findings.

Causes of COPDCauses of COPD

I.I. LocalizedLocalized A.A. CongenitalCongenital B.B. Compensatory due to lung collapse, scarringCompensatory due to lung collapse, scarring

or resectionor resection C.C. Partial bronchial obstructionPartial bronchial obstruction NeoplasmNeoplasm Foreign bodyForeign body D.D. MacLeod'syndromeMacLeod'syndrome II.II. GeneralizedGeneralized A.A. IdiopathicIdiopathic B.B. SenileSenile C.C. Familial (alpha-1-anti-trypsin deficiency)Familial (alpha-1-anti-trypsin deficiency) D.D. Associated with chronic bronchitis, asthmaAssociated with chronic bronchitis, asthma

or pneumoconiosis.or pneumoconiosis.

Risk-factors of COPD

External

Smocking (both active and passive)

Industrial and domestic pollutants

infection

Low social status (because of poor nutrition, overcooling, harmful habits)

Internal

Genetical predisposition (inherited deficiency of - α1-antitripsine)

Bronchial hyperreactivity

Hypoplasia of the lungs

Pathological mechanisms

Disorders of functional activity of ciliated epithelium

Change of sputum viscosity

Immunodepression (deranged cellular and humoral

defence)

Air pollutants inactivate α1-antitripsine and inhibitor of

elastase.

Clinical pattern

Complaints

Cough

Dyspnoe

General inspection

In later stage – diffuse cyanosis.

Inspection of the chest

In later stage – emphysematous chest

Palpation, percussion

On later stage – signs typical for pulmonary emphysema.

Auscultation

Weakened vesicular breathing with prolonged expiratory phase

Dry rales

Instrumental examination

External respiratory function

FEV1 < 80%

Tiffneu index < 70%

Spyrometry

(determination of FEV1, VLC, FVLC)

Tests with bronchodilators to estimate how much is bronchoobstruction

reverseble.

Clinical patternClinical pattern

The characteristic clinical features of The characteristic clinical features of chronic bronchitis and emphysema are chronic bronchitis and emphysema are cough, productive of thick yellow-green cough, productive of thick yellow-green sputum, wheeze and progressive sputum, wheeze and progressive breathlessness. breathlessness.

The symptoms are usually in winter and The symptoms are usually in winter and exacerbated by atmospheric pollution, dry exacerbated by atmospheric pollution, dry air, intercurrent infections and industrial air, intercurrent infections and industrial exposure to irritant gases or dusts.exposure to irritant gases or dusts.

Clinical pattern

Complaints

Expiratory dyspnoe

Inspection

Diffuse cyanosis

Swelling of neck veins

Inspection of a chest

Emphysematous chest

Protrusion of supra- and infraclavicular fossa

Participation of additional respiratory muscles

Palpation

Rigid chest

Percussion

Bundbox sound

Dislocation of lung upper border upward and the lower border -

downward

Wide Kroenig’s area

TreatmentTreatment The most important step in management is to persuade the patient to The most important step in management is to persuade the patient to

stop smoking. stop smoking. Bronchodilators may achieve some reversal of airways obstructionBronchodilators may achieve some reversal of airways obstruction Corticosteroids have a role in some patients. Corticosteroids have a role in some patients. Surgical removal of large bullae is occasionally helpful. Surgical removal of large bullae is occasionally helpful. Oxygen is usually given via nasal cannulae. Occasionally transtracheal Oxygen is usually given via nasal cannulae. Occasionally transtracheal

oxygen therapy (TTOT) via a small polyethylene catheter introduced oxygen therapy (TTOT) via a small polyethylene catheter introduced directly into the trachea. Long-term oxygen therapy from cylinders or an directly into the trachea. Long-term oxygen therapy from cylinders or an oxygen concentrator may be of value in patients with chronic stable oxygen concentrator may be of value in patients with chronic stable respiratory failure. The flow rate and concentration are adjusted to respiratory failure. The flow rate and concentration are adjusted to relieve arterial hypoxaemia while avoiding carbon dioxide narcosis.relieve arterial hypoxaemia while avoiding carbon dioxide narcosis.

Infections are frequent, and it is important to educate patients in the Infections are frequent, and it is important to educate patients in the early recognition of symptoms and signs, for example change of early recognition of symptoms and signs, for example change of sputum colour and quality, fever or increasing wheeze. Many patients sputum colour and quality, fever or increasing wheeze. Many patients should be given a supply of antibiotics to keep at home for self-should be given a supply of antibiotics to keep at home for self-medication. medication.