10 Obstructive

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Chronic Bronchitis

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• completely arbitrary clinical definition

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• a lot of mucous and glands

• normally: mucous layer 0.4 of total bronchiole wall. > 0.5 = severe bronchitis

• cough from inflammation

• wheezing from obstruction

• crackles from mucous

• left filled with mucous

• left become hypoxemic

• 100% O2 will not help

Emphysema

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• think smoke rising up to upper lobe

• acinus: "berry"

• smoker: branch portion, centriacinar or centrilobular

• deficiency: everything

• bronchus collapse during exhalation

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• big white space, thin septa (tissue dividing space)

• left lower: black spots, evidence of centrilobular damage

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• hyperventilation: to get remaining functioning alveoli to do more work

• hyperventilating = more work = weight loss

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• emphysema: blue line shift to left, less elastic recoil

• FRC shift up, higher volume at end of quiet breath, barrel chest

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AAT

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• balance elastase

• smoking: 60s-70s

COPD

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• usually just include chronic bronchitis and emphysema; asthma has its own treatment

Asthma

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• reversible: go back after acute episode

• overreact to stimulus and bronchorestrict

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• cold

• triggered by taking aspirin

• triad: asthma, rhinosinusitis, nasal polyposis

• Swollen ASA umpire: aspirin “pseudo-allergy” due to excess leukotriene synthesis (use clopidogrel instead)

• ASA umpire grabbing Coach Cox: inhibition of COX shifts the AA metabolism to the LOX leukotriene pathway (exaggerated in aspirin-induced asthma)

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• normal I/E: 1 to 2

• asthma: expiratory phase prolonged, longer for air to get out. 1/4 or 1/5

• reduced peak flow (image). Highest velocity of air flow

• status asthmaticus: severe, hypoxia

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• in mucous plugs in sputum: epithelial cells that shed and form whirls

• eosinophils and eosinophil membrane proteins making crystals

• drop in systolic blood pressure with inspiration, usually by pericardial effusion and tamponade

Bronchiectasis

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• chronic inflammation causing permanently dilated airways

• obstruction: small airways thickened

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• infection both cause and consequence

• rare cause of amyloidosis: anything causes chronic inflammation can lead to secondary amyloidosis

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• tumor: can't clear mucous, backs up

• smoking: either direct or by infection

• CF: recurrent infection

Ciliary Dyskinesia

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• either dynein absent or abnormal

• chronic sinusitis: poor ciliary function

• infertility: abnormal sperm ciliary

ABPA

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• only immunocompromised (asthma, CF)

• eosinophilia: important

• important: symptoms + blood IgE and eosinophils

• steroids: treat inflammation/allergic reaction

• plane with letters. Farmer running/migrating, sweating, inhaler in hand: ABPA (allergic bronchopulmonary aspergillosis) is a type I HSR that causes wheezing, fever and migratory pulmonary infiltrates. Also association with CF patients

• IgE on inhaler: ABPA is associated with asthma and may show increased IgE levels in the serum