RespPath-Lecture 6-Chronic Obstructive Lung Diseases-Part 2 of 4

Lecture 6
Prepared and presented by

Marc Imhotep Cray, M.D.
Photo: Colorized scanning electron micrograph of the lung, showing alveoli. Seeley’s Anatomy & Physiology. 10th ed. New York, NY: McGraw-Hill 2010
Respiratory Pathology
Lecture 6
Learning Objective
To provide the basic description, pathogenesis, types,
morphology (gross and microscopic), clinical presentation
(signs & symptoms) and complications of chronic bronchitis.
Marc Imhotep Cray, M.D. 2

Lecture 6
Chronic Bronchitis
 Patients with chronic bronchitis often have a history of recurrent
infection and abundant purulent sputum, followed by hypercapnia
and severe hypoxemia (blue bloaters)
 Important complication in severe bronchitis, in addition to

respiratory difficulties, is development of cor pulmonale and
eventual congestive heart failure, associated with secondary
pulmonary hypertension

Lecture 6
Chronic Bronchitis: Definition

Chronic bronchitis is defined clinically as persistent cough with
sputum production for at least 3 months of year, in at least 2
consecutive years
Clinically there are several forms of chronic bronchitis:

 Simple chronic bronchitis: Patients experience a productive cough
but have no evidence of airflow obstruction
 Chronic asthmatic bronchitis: Some patients may demonstrate
severe dyspnea and wheezing in association with inhaled irritants
or during respiratory infections due to hyperreactive airways.
 Chronic obstructive bronchitis: Some patients, especially heavy
smokers, develop chronic airflow obstruction, usually accompanied
by emphysema
Schematic representation Lecture 6
of overlap between
chronic obstructive lung
diseases:
Marc Imhotep Cray, M.D. Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. 2014 5
Lecture 6

Lecture 6
Pathogenesis of chronic bronchitis

Chronic irritation by inhaled
substances (cigarette smoking)
Infections
Adverse effects of smoking:

those that are more common
are in boldface
Marc Imhotep Cray, M.D. Kumar V and Abbas AK. Robbins and Cotran 7
Pathologic Basis of Disease 8th ed. 2014
Lecture 6
Pathologic characteristics of chronic

bronchitis
 Hyperemia, swelling, and bogginess of the mucous membranes are
main macroscopic features
 Frequently accompanied by excessive mucinous to
mucopurulent secretions covering epithelial surfaces
 Heavy casts of secretions and pus occasionally fill bronchi and

bronchioles

Lecture 6
Pathologic characteristics of chronic

bronchitis (2)
 The typical histologic feature of chronic bronchitis is enlargement
of mucus-secreting glands of trachea and bronchi
 Increase in size of mucous glands is assessed by ratio of thickness

of mucous gland layer to thickness of wall between epithelium and
cartilage (Reid index)
 Reid index is normally 0.4
 Marked narrowing of bronchioles caused by goblet cell metaplasia
also occurs, as do mucous plugging, inflammation, and fibrosis
 In most severe cases, obliteration of lumens (bronchiolitis

obliterans)
Lecture 6
Chronic bronchitis, microscopic

 Note increased
numbers of chronic
inflammatory cells
in submucosal
region
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015

Lecture 6
Clinical features of chronic bronchitis

 Persistent cough productive of copious sputum
 When persistent for years, eventually dyspnea on exertion
(DOE) develops
 In time, and usually with continued smoking, hypercapnia,

hypoxemia, and mild cyanosis with other elements of COPD may
appear
 Long-standing severe chronic bronchitis often results in cor

pulmonale with cardiac failure
 Complications of chronic bronchitis

 Obstruction of airway by mucus, leading to bronchiectasis or
atelectasis
 Pulmonary hypertension
Right-Sided Heart Failure: Lecture 6
Chronic Cor Pulmonale

 Chronic cor pulmonale typically develops in response to recurring
pulmonary thromboembolic disease or chronic pulmonary
parenchymal diseases, particularly chronic bronchitis and
emphysema
 Heart exhibits significant hypertrophy and dilatation of RV with a

normal-sized LV (unless the patient has other diseases, such as
systemic HTN or CAD)

Lecture 6
Right-Sided Heart Failure:

Lecture 6
Right-Sided Heart Failure:


Lecture 6
CASE 24
A 65-year-old man with a 40-year history of tobacco use and a
chronic productive cough for several years develops more
severe dyspnea and fever. He has an enlarged chest diameter
and some mild blueness to the lips. A chest radiograph shows
an enlarged heart and hyperlucent lung fields but no evidence
of a pulmonary infiltrate.
 What is the most likely diagnosis?
 What is the most likely underlying mechanism associated
with this disorder?

Lecture 6
CLINICAL CORRELATION
 This 65-year-old man has a long history of tobacco use, which is the most common
risk factor for chronic obstructive pulmonary disease (COPD).
 He complains of a several-year history of worsening dyspnea and a productive cough.
 He is in respiratory distress with labored respirations, cyanosis, a “barrel chest,”

wheezing, and distant heart sounds, all of which suggest lung disease.
 The main issue is his respiratory status.
 Rapid clinical assessment is critical in case this patient is headed toward respiratory
failure, necessitating intubation and mechanical ventilation.
 An arterial blood gas will give quick information regarding the oxygenation status as
well as the ventilatory efficiency via the PCO2 level.
 Bronchitis or pneumonia possibly has exacerbated his pulmonary disease.

Lecture 6
Q&A Review
1. A 54-year-old male smoker is diagnosed with chronic
bronchitis. A biopsy of the bronchus is performed. Which of
the following is the most likely finding on histology?
A. Abundant mucus with plugging of the bronchioles
B. Alveolar destruction and enlargement
C. Interstitial fibrosis
D. Noncaseating granuloma

Lecture 6
Q&A Review
2. A 46-year-old man complains of progressive dyspnea and
cough. He has been hospitalized multiple times over the last
2 years for respiratory distress. Bronchoscopy is performed
with biopsy of the lung. Histologic analysis reveals large
airspaces distal to the terminal bronchioles. Which of the
following is the most likely diagnosis?
A. Asthma
B. Bronchiectasis
C. Bronchitis
D. Emphysema
E. Sarcoidosis
Lecture 6
Q&A Review
3. A 29-year-old woman is noted to have chronic dyspnea
and easy fatigue with exertion. A chest radiograph reveals
hyperinflated lung fields without infiltrates. She denies a
history of cigarette smoking.
Which of the following is the most likely etiology for her
condition?
A. α1-Antitrypsin deficiency
B. Second hand smoke
C. Subclinical asthma
D. Amyloidosis

THE END
20
Lecture 6
Sources and further study:

Sources:
 Damjanov I, Pathology secrets 3rd ed. Philadelphia: Mosby, 2009
 Kemp WL, Burns DK and Brown TG. The Big Picture: Pathology. New York: McGraw-Hill,
2008
 Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015
 L. Maximilian Buja LM and Krueger GR. Netter’s Illustrated Human Pathology Updated Ed.
Philadelphia: Saunders, 2014
eLearning:
 IVMS General and Systems Pathology Cloud Folder
 Internet Pathology Laboratory for Medical Education: Pulmonary Pathology
Textbooks:
 Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed.
Philadelphia: Saunders, 2014
 Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine,
6th Ed. Baltimore: Lippincott Williams & Wilkins, 2012
Lecture 6
e-Medicine Articles (Clinical)

Obstructive Airway Diseases
• Alpha1-Antitrypsin Deficiency
• Asthma
• Bronchiectasis
• Bronchiolitis
• Bronchitis
• Chronic Bronchitis
• Chronic Obstructive Pulmonary Disease
• Emphysema
• Status Asthmaticus

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Lecture 6

Prepared and presented by

Marc Imhotep Cray, M.D. 2

 Important complication in severe bronchitis, in addition to

Marc Imhotep Cray, M.D. 3

Chronic Bronchitis: Definition

Clinically there are several forms of chronic bronchitis:

Marc Imhotep Cray, M.D. 6

Pathogenesis of chronic bronchitis

Adverse effects of smoking:

Pathologic characteristics of chronic

 Heavy casts of secretions and pus occasionally fill bronchi and

Marc Imhotep Cray, M.D. 8

Pathologic characteristics of chronic

 Increase in size of mucous glands is assessed by ratio of thickness

 In most severe cases, obliteration of lumens (bronchiolitis

Chronic bronchitis, microscopic

Marc Imhotep Cray, M.D. 10

Clinical features of chronic bronchitis

 In time, and usually with continued smoking, hypercapnia,

 Long-standing severe chronic bronchitis often results in cor

 Complications of chronic bronchitis

Right-Sided Heart Failure: Lecture 6

Chronic Cor Pulmonale

 Heart exhibits significant hypertrophy and dilatation of RV with a

Marc Imhotep Cray, M.D. 12

Marc Imhotep Cray, M.D. 13

Right-Sided Heart Failure:

Marc Imhotep Cray, M.D. 14

Marc Imhotep Cray, M.D. 15

 He complains of a several-year history of worsening dyspnea and a productive cough.

 He is in respiratory distress with labored respirations, cyanosis, a “barrel chest,”

 The main issue is his respiratory status.

 Bronchitis or pneumonia possibly has exacerbated his pulmonary disease.

Marc Imhotep Cray, M.D. 17

Marc Imhotep Cray, M.D. 19

Sources and further study:

e-Medicine Articles (Clinical)

Marc Imhotep Cray, M.D. 22

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