Pathology of The Lung

(Robbins Pathologic Basis of Disease 9th Ed. 2015; p 669-726)

Djumadi Achmad
 Atelectasis (Collapse of the Lung)

1. Congenital (neonatal atelectasis)

2. Acquired atelectasis :
• Resorption atelectasis : caused by complete obstruction of an
airway 
– Mucus plugs or exudates within smaller bronchi :
• Asthma, chronic bronchitis, bronchiectasis, and
postoperative states
– Aspiration of foreign bodies
 Atelectasis (Collapse of the Lung)

2. Acquired atelectasis :
• Compression atelectasis  whener within the pleural cavity
accumulate : fluid (transudate, exudate or blood), tumor or air
(pneumothorax)
• Contraction atelectasis occurs when focal or generalized
pulmonary or pleural fibrosis
 Acute Lung Injury and
Acute Respiratory Distress Syndrome
• Acute lung injury (ALI) : abrupt onset of significant hypoxemia
and bilateral pulmonary infiltrates in the absence of cardiac
failure.
• Acute respiratory distress syndrome (ARDS) is a manifestation
of severe ALI.
 Pathogenesis ALI/ ARDS

• Endothelial activation : by mediators.

• Adhesion and extravasation of neutrophils.
• Accumulation of intraalveolar fluid and formation of hyaline
membranes.
• Resolution of injury is impeded in ALI/ ARDS due to
epithelial necrosis and inflammatory damage
KEY CONCEPTS

Acute Respiratory Distress Syndrome

• ARDS is a clinical syndrome of progressive respiratory
insufficiency caused by diffuse alveolar damage in the setting of
sepsis, severe trauma, or diffuse pulmonary infection.
• Damage to endothelial and alveolar epithelial cells, with
inflammation, are the key initiating events and the basis of lung
damage.
• The characteristic histologic picture is that of hyaline membranes
lining alveolar walls. Edema, scattered neutrophils and
macrophages, and epithelial necrosis are also present.
 Obstructive Lung Diseases

• Emphysema
COPD (chronic obstructive
• Chronic bronchitis pulmonary disease)
• Asthma
• Bronchiectasis
 Emphysema

Characterized by irreversible enlargement of the airspaces

distal to the terminal bronchiole, accompanied by destruction
of their walls without obvious fibrosis.

Four major types:

1. Centriacinar (centrilobular) - most common
2. Panacinar (panlobular)
3. Paraseptal (distal acinar)
4. Irregular

Only the first two cause clinically significant airflow obstruction.

 Pathogenesis of Emphysema

• Cigarette smoke and other noxious particles  lung damage

and inflammation 
– Parenchymal destruction (emphysema)
– Airway disease (bronchiolitis and chronic bronchitis)
• Contributing factors :
– Inflammatory mediators and leukocytes
– Protease-antiprotease imbalance
– Oxidative stress
– Infection
Pathogenesis of Emphysema
 Factors that contribute to airway obstruction in
emphysema

• Goblet cell hyperplasia, with mucus plugging of the lumen

• Inflammatory infiltrates in bronchial walls consisting of
neutrophils, macrophages, B cells, and T cells
• Thickening of the bronchiolar wall due to smooth muscle
hypertrophy and peribronchial fibrosis
Other Forms of Emphysema

• Compensatory emphysema : dilation of alveoli in response to

partial loss of lung parenchyma.
• Obstructive emphysema : common cause is subtotal
obstruction of the airways by a tumor or foreign body.
• Bullous emphysema : large subpleural blebs or bullae that can
occur in any form of emphysema.
• Interstitial emphysema : entrance of air into the connective
tissue stroma of the lung, mediastinum, or subcutaneous
tissue
KEY CONCEPTS

Emphysema
• Emphysema is a chronic obstructive airway disease characterized by
permanent enlargement of air spaces distal to terminal bronchioles.
It is a component of COPD (chronic obstructive pulmonary disease)
along with chronic bronchitis.
• Subtypes include centriacinar (most common, smoking related),
panacinar (seen in a 1-antitrypsin deficiency), distal acinar and
irregular.
• Smoking and inhaled pollutants cause ongoing accumulations of
inflammatory cells, releasing elastases and oxidants, which destroy
the alveolar walls.
• Most patients with emphysema also have some degree of chronic
bronchitis, which is to be expected since cigarette smoking is an
underlying risk factor for both.
 Pathogenesis of Chronic Bronchitis

The primary or initiating factor is exposure to noxious or

irritating inhaled substances such as tobacco smoke (90% )
and dust from grain, cotton, and silica.
Features :
• Mucus hypersecretion
• Inflammation
• Infection
KEY CONCEPTS

Chronic Bronchitis
• Chronic bronchitis is defined as persistent productive cough for at
least 3 consecutive months in at least 2 consecutive years.
• Cigarette smoking is the most important risk factor; air pollutants
also contribute.
• The dominant pathologic features are mucus hypersecretion and
persistent inflammation.
• Histologic examination demonstrates enlargement of mucous-
secreting glands, goblet cell hyperplasia, chronic inflammation, and
bronchiolar wall fibrosis.