8.2 Obstructive and Restrictive Pulmonary Disorders

Obstructive and restrictive pulmonary disorders affect breathing in different ways. Obstructive disorders limit airflow, while restrictive disorders reduce lung volumes. Both can cause shortness of breath and other respiratory symptoms.

Management of these disorders involves various diagnostic tests and treatments. Bronchodilators and corticosteroids are common for obstructive disorders, while restrictive disorders may require treatment of underlying causes and supportive care.

Obstructive Pulmonary Disorders

Obstructive vs restrictive pulmonary disorders

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• Obstructive pulmonary disorders
  • Airflow limitation impairs normal breathing characterized by increased airway resistance
  • Normal or increased total lung capacity (TLC) due to air trapping
  • Decreased forced expiratory volume in 1 second (FEV1) indicates difficulty exhaling quickly
  • Reduced FEV1/FVC ratio below 70% suggests airflow obstruction (FVC: forced vital capacity)
• Restrictive pulmonary disorders
  • Reduced lung volumes limit the amount of air the lungs can hold
  • Decreased TLC indicates overall reduction in lung capacity
  • Normal or increased FEV1/FVC ratio as both values decrease proportionally
  • Reduced lung compliance makes breathing more difficult due to stiff lung tissue
• Clinical presentation differences
  • Obstructive: wheezing during exhalation, prolonged expiration, barrel chest deformity
  • Restrictive: rapid, shallow breathing pattern, reduced chest expansion during inhalation

Pathogenesis of obstructive pulmonary disorders

• Chronic Obstructive Pulmonary Disease (COPD)
  • Pathogenesis
    • Chronic inflammation of airways leads to thickening and narrowing
    • Destruction of lung parenchyma results in emphysema and reduced gas exchange
    • Loss of elastic recoil impairs ability to fully exhale
  • Risk factors
    • Smoking tobacco primary cause of COPD
    • Occupational exposure to irritants (dust, chemicals, fumes)
    • Alpha-1 antitrypsin deficiency genetic disorder increases susceptibility
  • Clinical manifestations
    • Chronic cough often worse in mornings
    • Sputum production may be clear, white, or yellowish
    • Dyspnea on exertion progressively worsens over time
    • Pursed-lip breathing helps relieve shortness of breath
• Asthma
  • Pathogenesis
    • Airway hyperresponsiveness causes exaggerated bronchial constriction to stimuli
    • Reversible bronchoconstriction occurs during asthma attacks
    • Chronic airway inflammation leads to remodeling over time
  • Risk factors
    • Genetic predisposition increases likelihood of developing asthma
    • Allergies to environmental substances (pollen, dust mites)
    • Environmental triggers (cold air, exercise, stress)
  • Clinical manifestations
    • Episodic wheezing during asthma exacerbations
    • Chest tightness sensation of constriction
    • Shortness of breath varies in severity
    • Nocturnal cough often worse at night or early morning

Restrictive Pulmonary Disorders

Features of restrictive pulmonary disorders

• Interstitial lung diseases (ILDs)
  • Pathophysiology
    • Inflammation and fibrosis of lung interstitium reduce lung elasticity
    • Reduced lung compliance increases work of breathing
    • Impaired gas exchange leads to hypoxemia
  • Causes
    • Idiopathic pulmonary fibrosis unknown etiology
    • Sarcoidosis granulomatous disease affecting multiple organs
    • Occupational exposures (asbestosis, silicosis, coal worker's pneumoconiosis)
  • Clinical features
    • Nonproductive cough dry and persistent
    • Progressive dyspnea worsens over time
    • Fine crackles on auscultation heard at lung bases
    • Clubbing of fingers late sign of chronic hypoxemia
• Neuromuscular disorders affecting the respiratory system
  • Pathophysiology
    • Weakness of respiratory muscles impairs ventilation
    • Reduced lung volumes due to inadequate inspiration
    • Impaired cough reflex increases risk of respiratory infections
  • Causes
    • Amyotrophic lateral sclerosis (ALS) progressive motor neuron degeneration
    • Myasthenia gravis autoimmune disorder affecting neuromuscular junction
    • Guillain-Barré syndrome acute inflammatory demyelinating polyneuropathy
  • Clinical features
    • Shortness of breath initially with exertion, progresses to rest
    • Orthopnea difficulty breathing when lying flat
    • Weak cough ineffective clearance of secretions
    • Respiratory failure in advanced stages may require ventilatory support

Management of pulmonary disorders

• Diagnostic approaches
  • Pulmonary function tests (PFTs)
    • Spirometry measures airflow and lung volumes
    • Lung volumes measurement assesses TLC and residual volume
    • Diffusion capacity evaluates gas exchange efficiency
  • Imaging studies
    • Chest X-ray identifies structural abnormalities
    • High-resolution computed tomography (HRCT) detailed lung parenchyma imaging
  • Blood gases analysis assesses oxygenation and ventilation
  • Exercise testing evaluates functional capacity and oxygen needs
• Management strategies for obstructive disorders
  • Bronchodilators (beta-2 agonists, anticholinergics) relax airway smooth muscle
  • Inhaled corticosteroids reduce airway inflammation
  • Smoking cessation crucial for slowing COPD progression
  • Pulmonary rehabilitation improves exercise tolerance and quality of life
  • Oxygen therapy for severe cases with chronic hypoxemia
• Management strategies for restrictive disorders
  • Treatment of underlying cause (if known) may slow disease progression
  • Corticosteroids for inflammatory conditions reduce lung inflammation
  • Antifibrotic medications for certain ILDs (pirfenidone, nintedanib)
  • Supportive care and symptom management improve quality of life
  • Mechanical ventilation for respiratory failure when necessary
• General management approaches
  • Vaccination against respiratory infections (influenza, pneumococcal)
  • Nutritional support maintains muscle strength and immune function
  • Patient education on disease management improves self-care
  • Regular follow-up and monitoring of disease progression guides treatment adjustments