Biology of Disease
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Biology of DiseaseBiology of Disease
CH0576
Respiratory Disorders I
Dr Suad Awads.awad@northumbria.ac.ukRoom A305 Ellison’s- Ext 3816
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* Identify lung volumes & capacities
Lecture Objectives
* Explain effect of relevant pressures in pulmonary ventilation
* Discuss causes and consequence of Pneumothorax
* Explain the aetiology of obstructive lung disease
* Explain the basis of pulmonary compliance
* Discuss causes and pathological features of Asthma
* Discribe pathological features ofRespiratory Distress Syndrome
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* Spirometry: Lung Volumes & Capacities
Lecture Outline
* Pneumothorax
* Resistance to Airflow
* Chronic Obstructive Lung Diseases: Asthma
* Pulmonary Compliance: Respiratory Distress Syndrome
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Lung Volumes & Capacities
Classic Spirometer
Fig 26-1A- Boron
Spirometry: Measure air
entering or leaving lung
Change in Lung Volume
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Lung Volumes & Capacities
Fig 26-1B- Boron
TV= Tidal volumeIRV= Inspiratory Reserve
Volume
ERV= Expiratory ReserveVolume
RV= Residual Volume Air remaining in lung after max exp effort
RV= Can not be measured by a Spirometer
Max volume expired at end of quiet expiration
Max volume inhaled at end of quiet inspiration
Inspiration: Upward deflection,
Expiration: Downward deflection
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Lung Volumes & Capacities
Fig 26-1B- Boron
TLC= Total Lung CapacitySum of all 4 volumes
FRC= Functional Residual capacity
Sum of ERV + RVAir remaining after
quiet expiration
IC= Inspiratory CapacitySum of IRV + TV max inspired volume after a quiet expiration
VC= Vital CapacitySum of IRV + TV + ERV max inspired achievable tidal volume
Any capacity that includes the RV can not be measured
by a Spirometer
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Lung Volumes & Capacities
Fig 26-1B- Boron
FEV1
Forced Expiratory Volume in One Second
~ 80% VC in Healthy Young Adults
Affected in Pulmonary Disorders with increased
Airway resistance Eg Asthma
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Lung Volumes & Capacities
Volumes & Capacities Typical Ranges (L)
IRV (Inspiratory Reserve Volume) 1.9- 2.5
TV (Tidal Volume) 0.4- 0.5
ERV (Expiratory Reserve Volume) 1.1- 1.5
RV (Residual Volume) 1.5- 1.9
TLC (Total Lung Capacity) 4.9- 6.4
IC (Inspiratory Capacity) 2.3- 3.0
FRC (Functional Residual Capacity) 2.6- 3.4
VC (Vital Capacity) 3.4- 4.5
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Spirometry: FEV1/VC ratio
• FEV1 This is the forced expiratory volume in one second. It reflects airway narrowing and is
relatively independent of effort
• FVC = the forced vital capacity Normally FEV1 = 70%-80% of the FVC
FEV1 and FVC used to differentiate betweenObstructive and Restrictive patterns of lung disease
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Peak Flow Metre• Peak Expiratory Flow Rate (PEFR) is defined as the highest air flow (Vol/time) achieved at the mouth during a forced expiration
• It is a measure of the existence and severity of airflow obstruction
• The PEFR obtained by a patient is compared to that of a normative standard (use height, age, gender). It is calculated as % of the expected PEFR.
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Peak Flow Meter
Measured by modern Spirometry: Next Lecture
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FRCFunctional Residual Capacity
Determined by the lung and chest wall elastic recoils
Volume of air remaining in the lungs at the end of a quiet expiration
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Factors affecting Ispiratory & Expiratory Reserve Volumes
* Current Volume
* Lung Compliance
* Muscle Strength
* Comfort
* Posture
A measure of how easy to inflate the lungs
The greater the current volume, the less are the reserve volumes
Problems with innervation - muscle weakness
Pain (injury) limit desire or ability to make insp efforts
Recumbent position = IRV falls- Difficult for diaphragm to move abdominal contents
* Flexibility of SkeletonArthritis, Kyphoscoliosis = Reduce IRV
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Important Pressures in Pulmonary Important Pressures in Pulmonary VentilationVentilation
* Atmospheric Pressure - Barometric pressure
* Intra-alveolar Pressure - Pressure within the alveoli Fluctuates during breathing cycle: -ve inspiration, +ve expiration
* Intrapleural Pressure - Pressure inside the thoracic cavity
Less than Barometric P (-ve)
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Pneumothorax• Occurs when the Intrapleural Pressure
equilibrates with atmospheric P.As a result lungs collapse - inherent elastic recoil
• Traumatic Pneumothorax - caused by the chest wall being punctured
• Spontaneous Pneumothorax - 1. Due to a hole in the wall of the lung 2. Congenital defect in connective tissue in alveolar wall
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Traumatic
Spontaneous
COLLAPSED LUNG
Pneumothorax
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Pneumothorax
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Factors Influencing Airflow ThroughFactors Influencing Airflow Through the Lungthe Lung
Airflow (F) depends on: 1. Pressure Gradient P- Difference between atmospheric pressure and intra-alveolar pressure.
2. Resistance of Airways (R)- Determined by the radii of the airways
F is inversely related to R F = P/R
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Resistance to AirflowResistance to Airflow
F = P/R • Main determinant of resistance to airflow (R) is the RADIUS of the conducting airways • In the healthy lung the radius is relatively large and so R is low
• The airways normally offer such a low resistance that only small pressure gradients are needed for adequate airflow into the lung
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Adjustment of Airway SizeAdjustment of Airway Size
• Normally modest changes in airway size, to meet the body’s needs, are achieved through the AUTONOMIC nervous system
• In quiet respiration Parasympathetic stimulation promotes bronchiolar smooth muscle contraction causing Bronchoconstriction Maintains muscle tone in airways
• Sympathetic stimulation brings about Bronchodilation by bronchiolar smooth muscle, Decreasing airway resistance during exercise, fight or flight situations
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Pulmonary Diseases Associated Pulmonary Diseases Associated with Narrowing of the Airwayswith Narrowing of the Airways
• Increased Resistance is an extremely important impediment to airflow when airways become narrowed due to disease:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
• COPD is a group of lung diseases including - Chronic Bronchitis, Asthma and Emphysema
• COPD is characterised by Increased Airway Resistance
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Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease
* Sufferers have to work harder to breathe
• F = P/RWhen resistance is increased, a larger pressure gradient is needed to maintain a normal airflow.e.g. If resistance is doubled by narrowing of airway lumens, P must be doubled through increased respiratory muscle workload
• Expiration is more difficult to accomplish than inspiration giving rise to the characteristic ‘WHEEZE’ as air is forced out of narrow airway
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Chronic Obstructive Lung Diseases (COPDs)
• Group of diseases in which there is a chronic limitation to airflow
• Flow is reduced for one of two reasons:
1. Narrowing of the Airways causing increased resistance - Asthma, Chronic Bronchitis 2. Loss of Elastic Recoil - Reduction in the outflow pressure - Emphysema
Aetiology:
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Asthma• Asthma is the Greek word for ‘Breathless’ or ‘to breathe opened mouthed’
• It is caused by Chronic Inflammatory Responses in the airways
• This leads to REVERSIBLE airway obstruction.
• It is characterised by breathlessness and wheezing
caused by generalised narrowing of intrapulmonary airways
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Causes of Asthma
Asthma is a heterogeneous disease triggered by a variety of inciting agents (Genetic + Environ)
• Extrinsic Factors Caused by Type I hypersensitivity reactions on exposure to extrinsic allergen (pollen, perfume,
dust mite, others?)
• Intrinsic Factors Non-immune trigger mechanism e.g. hormonal, stress, exercise
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AsthmaThere are three main features of asthma:
Remember: (F = P/R)
1. Muscle Spasm – Bronchospasm (Narrowing of airway lumen- increased airway R)
2. Mucus Plugging- (air trapping in distal bronchioles- increased RV, and relevant volume & capacities; eg? )
3. Mucosal Oedema- (Narrowing of lumen- increased R- increased pressure- increased work for respiratory muscles)
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Pathological Features of Asthma
* Mucosal Oedema- Inflammatory cell infiltration (Eosinophils 5%-50%)
- Basement membrane thickening
- Goblet cell and submucosal gland hyperplasia- Hypertrophy and hyperplasia of the smooth muscle in the bronchial wall
These events lead to - Airway Obstruction Bronchial Muscle Constriction Airway Congestion
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Early phase
response in asthma
SM spasm followed By inflammation
Histamine inducesSM contractionThrough H1 Rs
Lamina propria
Dust mite, pollenOther??
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Late phase response in asthma
Eosinophill Infiltration, (MBP, ECP)
Loss of Epithelial Cells
Increased mucussecretion
SM Hypersensitivity
(histamine),Infiltration ofBasophils & Neutrophils
Edema
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Pathological Features of Asthma
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Bronchioles in AsthmaBronchioles in Asthma
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Features of Asthma in Status Asthmatics
• Lungs are Overdistended - Due to trapped air• May be small areas of Atelectasis• The most striking feature is the blocking of bronchi and bronchioles with thick mucus plugs
• The mucus plugs contain - Whorls of shed epithelium - Eosinophils - Charcot - Leyden Crystals
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Charcot Leyden CrystalsCharcot Leyden Crystals
Crystallised LysophospolipaseEnzyme produced
By Eosinophils
Up to 50 mlength
Normally colourlessStains reddish by
trichrome
Indicative of a disease involving eosinophilic inflammation& proliferation
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Asthma - Clinical Course
• Severe Dyspnoea with wheezing
• Hyperinflation of lungs, with air trapped distal to the bronchi which are constricted and full of mucus (which volumes & capacities are affected?)
• This leads to Hypercapnia, acidosis and hypoxia
• Asthma tends to be severely debilitating rather than lethal
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COMPLIANCECOMPLIANCE• A factor influencing the pressure gradient P in the lung is the ELASTIC behaviour of the lung
• This affects alveolar and lung volume, and therefore the pressure gradient needed to inflate lung
• COMPLIANCE refers to how much effort is required to stretch or distend the lungs
• Specifically Compliance is a measure of the change in lung volume due to a given change in transmural pressure (The Force That Stretches the Lung)
C = V/ P
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COMPLIANCECOMPLIANCE
• A HIGHLY compliant lung stretches further for a given increase in pressure than does a LESS compliant lung (eg inflating a very flexible Vs stiff balloon)
• A LESS compliant lung will require MORE Effort (P) to produce a given degree of inflation
• A POORLY compliant lung is referred to as a ‘STIFF LUNG’
• Compliance is reduced in pulmonary diseases e.g. FIBROSIS of the lung
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Factors Affecting Pulmonary ComplianceFactors Affecting Pulmonary Compliance
Pulmonary compliance depends on various factors:
1. Highly Elastic Connective Tissue
2. Alveolar Surface Tension:- due to a
thin liquid film lining each alveolus.
It resists any force that increases
surface area (thus OPPOSES expansion)
3. Pulmonary Surfactant:- Surface Active Agent - detergent !
produced by TYPE II alveolar cells, decreases surface
tension (70 dynes/cm Vs 25 dynes/cm)
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Pulmonary CompliancePulmonary Compliance
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Effect of Pulmonary SurfactantEffect of Pulmonary Surfactant
• It REDUCES the surface tension and contributes to lung stability
• It acts by interspersing water molecules lining the alveolus, which reduces surface tension
Benefits of Reducing Surface Tension:
a) Increases pulmonary compliance - thus reducing the effort needed to inflate the lungs
b) It stabilises the alveoli so they do not collapse at end of expiration
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Newborn Respiratory Distress SyndromeNewborn Respiratory Distress Syndrome
• Surfactant produced by 34th wk gestation * Premature infants- Deficiency in lung surfactant
leads to Newborn Respiratory Distress Syndrome
• Very strenuous inspiratory efforts are required to overcome the high surface tension in the alveoli The lungs are Poorly Compliant
• It may require transmural pressure gradients of 20-30 mm Hg (normally 4-6 mm Hg) to overcome the tendency of the lungs to collapse
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NEWBORN RDS
• The problem is compounded as the newborn’s muscles are still very weak
• Deficiency in surfactant leads to alveolar instability and severe respiratory failure
• Life threatening condition
• Newborn RDS can be treated by: a) Artificially increasing atmospheric pressure b) Treating with exogenous surfactant
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Useful Textbooks
Rhoades & Bell, 3rd ed. Medical Physiology: Principles of Clinical Medicine. LWW
Boron & Boulpeap, 2nd ed. Medical Physiology: Saunders
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