A Scientific and Social essay

Pulmonary Emphysema as a Scientific and Social Problem

Aetiology Pathogenesis and Prevention of Pulmonary Emphysema

Cigarette Smoking as a Cause

Américo González-Bogen

 

Abstract

Pulmonary Emphysema is produced by Sympathetic Adrenergic hyperactivity since this increases the autonomic dynamics of the respiratory structures (lobules) of the Lung.

Pulmonary Emphysema is a long-lasting hyperkinetic process of the pulmonary lobules, leading to elongation and rupture of elastic structures and alveolar walls and septum, thus generating great cavities where air is retained. This process conveys pulmonary and cardiac insufficiencies manifested as Respiratory Insufficiency and Chronic Pulmonale Cor.

Cigarette smoking gather optimal conditions to generate Pulmonary Emphysema because:Its nicotine content
Repeated inhalation many times a day, all days during many years
Additional supplies by the smoke, which content Nicotine in suspension.

Physical damage of Pulmonary Emphysema is irreversible
To stop smoking stop progress of the damage
Prevent smoking is prevention of Pulmonary Emphysema

 

Introduction

The elastic structure of the lung is well known today and, descriptions have been carried out both in normal lungs as in specimens with Emphysema.
This complex structure is in synthesis an elastic framework extended from the roots of each bronchial tree to the visceral pleura. Meanwhile Pulmonary Emphysema defines as elongation, distortion, and rupture of elements of this structure, generating great cavities where air retains

Nevertheless, the cause and pathogenesis of this structural damage remains ignored until now, although so many hypotheses are proposed.

 

The reason for the lack of understanding of this pathological process and its cause is the prevalence of the traditional theory of the pulmonary mechanics, which considers the lung a passive organ motorised by the Diaphragm.

 

In other context, to "see and project into space and time" how the pulmonary structure works, from my perspective, as Discoverer and interpreter of the Resultant of the pulmonary mechanics on the visceral pleura "The Respiratory Pulse"(1), to achieve the Respiratory Function, is something impressive

Add to that primary scenery the consequent understanding of the pulmo-cardiac balanced functional integration at the alveolo-capillary units, commanded by the Lung. Also, add to it the other main role of the Lung in the permanent cyclic dynamic integration of the Organism with the Atmosphere of the Earth, at the level of its adaptation. Then you will understand the functional integration of the working parts of the Organism in itself as with the Atmosphere, which is the Conception of the Organo-Physical Nature to maintenance of Life on the Earth

The dynamic balanced performance of the Lung, under Vagus Sympathetic control, can change during every day life, because alterations in the factors of the equation of the Respiratory Function (2)

I have demonstrated that the lobular bronchioles and alveoli are structures with specific dynamics to perform balanced gas exchange with the blood, under Sympathetic control. To achieve this commitment the lobules and the right ventricle of the Heart carry out integrated and balanced cyclic dynamics

 

This is, probably, my must striking discovery about the physical functional interpretation of the mechanics of the lung and, is the key to understand the pathogenesis and cause of Pulmonary Emphysema.

 

Facing the Truth

The traditional interpretation of the respiratory cyclic mechanics is limited to the apparent phases of Inspiration and Expiration. This is a basic error that hide the truly sequence of air circulation throughout the functional complexity of the airways, impeding any possibility of understanding the respiratory physiology and physio-pathology

Both the ventilatory mechanics (lobar air renovation) and respiratory mechanics, strictus sense (gas exchange with the blood) consist in the intake and balanced ejection of air masses previously conditioned in the extra-pulmonary airways, followed by expansion, use and cyclic renovation by each one of the functional sectors of the lobar bronchi and lobular bronchioles.

 

The permanent cyclic air renovation and conditioning is relative to the need of balancing the air mass per volume unit demanded by the autonomous programming of the Lung at the alveolar level.

 

The Process

To start with, it is necessary to bear in mind the conditions of the inspired air at the geographical level of our natural adaptation, to then better understanding the role of the respiratory airways, beginning at the nasopharynx

Afterwards we must consider the successive divisions of this mass of air, while successively displaced through the lobar bronchi first and lobular bronchioles then, each one in its own sector, to achieve proper objectives, and simultaneous complementation

The ventilatory stage at the lobar level (air renovation into the lobes, by the lobes) began with a Vagus nerve discharge generating contraction of the smooth muscles of the lobar bronchi.
This muscular contraction diminishes the bronchial capacity and pressurises the contained air, displacing it towards the distal airways, on the lobar periphery.

This mechanics, not formerly perceived coincides in time with the known Expiration at the nasal level. Nevertheless, these are different mechanical phenomena carried out in different sectors, each one with proper partial objectives.

The air mass inspired in each ventilatory cycle is retained in the nasopharinx to be then displaced during successive cycles until arrive to the insertion points of the lobar main bronchi, in their respective major right and left bronchus.

 

THE LOBES

The lobar bronchi suck the air mass in the very moment of their muscular relaxation, and will remain here until the next muscular contraction. This is the starting point for each cycle of lobar air renovation.

Pulmonary dynamics is better understand if it is thought as similar, as it is, to cardiovascular dynamics, where systole or cardio-contraction, constriction-retraction is similar to broncho-contraction constriction-retraction and "The Respiratory Pulse"(1) -expansion is similar to broncho-relaxation- expansion.
The objectives of the two visceral dynamics are similar: the cardiac and pulmonary muscular contractions are carried on to generate the necessary forces to displace forwards the respective fluid masses contained inside
The following cardiac relaxation has as an objective to receive the blood coming from the auricle, while the lobar bronchial relaxation achieves two simultaneous objectives:

  1. In its proximal end, where receives and sucks, from the right or left major bronchus, the masses of delivered air, to replace that previously displaced.
  2. In its distal end, to enable expansion of the mass of air formerly displaced at pressure,

The expansive forces of the previously pressurised air distend the elastic bronchial structures ("action"), creating an increase in capacity and hence a new volume-pressure balance of the masses of air. This is in accordance with their cyclic proportional use by the corresponding lobular structures. This "action" generates the physical "reaction", which is similar and, is warrant of the known elastic retraction force of the lobar structure, to create mechanical conditions for the next cycle.

 

The Lobules and Alveoli

One must made for the lobules a similar analogy to the formerly described for the lobes. The lobular bronchioles-constriction-retraction displaces, towards the alveoli; the small masses of air aspired from the lobes. The lobular-retraction increases the pleural lumen, opening ways to the capillary blood circulation for simultaneous arrival of air and blood.

The following bronchiolar relaxation allows expansion of the contained mass of air, which consequently distension of the finest structures of the respiratory bronchioles and alveoli.

 

This is the transcendental time and dynamic conditions for gas exchange. With the blood

 

One step of elastic retraction of the lobular structures takes place at the end of each cyclic lobular relaxation. This fact helps in the displacement, in converse sense, of the alveolar used air, also allowing one degree of air pressure balance and dynamic conditions to start the next lobular cycle.

It is of the maximal importance to remember here that the Sympathetic-Adrenergic subsystem regulates the lobular dynamic cycles, thus integrating the synchronous cardiac dynamics, both having as a basis the mechanical conditions controlled by the Vagus nerve

 

Functional Integration

This visceral dynamic integration, under Vagus and Sympathetic control puts into evidence that the Vagus and Sympathetic autonomous subsystems are not antagonistic as believed, but complementary. (This evidence must help to re-interpret other actions of the autonomous system).

The lobar bronchial structure elastically retracts by steps, at the measure in which the lobules use and expel the mass of air formerly sucked from the lobes. That is to say, the previously expanded lobular structure retracts in so many steps as the number of lobular cycles comprised in one lobar cycle. Consequently, these steps elapse so long as is the time consumed by the number of cardiac bits and lobular contractions comprised into one Ventilatory cycle
The lobules employ the ventilatory period in use and expel, by fractions, a mass of air similar to that inspired in the corresponding ventilatory cycle.
The small masses of used and expelled air will be stored into the tracheo-bronchial airway until the next vagal muscular contraction to expel it towards the Atmosphere.

 

The Emphysema Process

 

The physiologic dynamics of the lobules is relative to the magnitude and frequency of the Sympathetic nerve discharges. This dynamics is altered by any possible discharges of Adrenaline and sympathetic-mimetic drugs coming from other ways, physiologic, pathologic or because external supply, voluntary or not.

 

One inference is clear; hyperactivity of the lobular bronchioles can be generated by many causes, idiopathic or not, sometimes ease to define.
Another parallel, general concept is that any functional structure, physical or organic, becomes weaker by continuous use.

 

We know, by anatomo-pathological studies, that the pulmonary lobules can suffer of different degrees of distension, rupture an even destruction of their elastic structures, as in Pulmonary Emphysema, which pathogenesis I try to disclose here.

 

In regard to above said, think about the lobular bronchioles and compare them with an arterial trunk an its divisions. Think about normal arterial pressure and hypertension, with its potential consequences and deduce yourself the physio-pathological consequences of the lobular air hypertension upon their finest structures.

 

Think about the possibility of repeated hyperdistension of the finest elastic fibres and, the possibility of their repeated elongation, residual damages and even ruptures. Also, think that this effect shall be accumulative if the incident factor were repetitive and prolonged on time. This process would lead to destruction of the named elastic structures and alveolar septum, in the successive degrees that characterises the evolution of the process.

 

Also think about the bronchiolar vessels which could be distended because hyperexpansion of the bronchiolar structure, collapsing their lumen and, deduce potential damages in cellular feeding, which decreases resistance to elongation and favours rupture, including the same vessels. Deposits of pigment testify this assumption.

Think now about the alveolar capillaries, which distend by hiperexpansion of the alveolar membrane, collapsing their lumen, disturbing the alveolar capillary circulation, and consequently disturbing gas exchange. Also think that this disturbance on capillary blood circulation convey retardation of the pulmonary circulation with retrograde effects, leading to Chronic Cor Pulmonale.
I have explained apart the development of the pathological process and clinical effects, which are detectable and interpretable now.

Lets think for a moment about the Lungs of individuals of advanced age, as described in pathological Anatomy. Their elastic structures have received the physiological impact of the named cyclic dynamics during so many years, that they show "fatigue by use", predominantly of the finest ones: respiratory bronchioles, and alveoli. This is the named "ageing pulmonary emphysema". This is the result of impact of the physiological dynamics repeated so many times as expressed by calculation of the number of cardio-lobular cycles by minute, by hour, by day, by month, by year, multiplied by the number of years of a prolonged life.

 

A question posed now is the value of the minimal force, generated in normal life, which could be able of producing distension and rupture. I do not think it is possible, I believe an additional factor must be present

 

Think now on any theoretical case, also at advanced age, with Sympathetic Adrenergic hyperchinetics, idiopathic or of discernible origin. Think about the potential evolution of that hyperactivity and their accumulative sequels and, you will be facing the developing and/or advanced features of "pure" Pulmonary Emphysema or of the so called "Chronic Obstructive Pulmonary Disease", when associated factors exist.

Think now about the thousands times repeated that the Pulmonary Emphysema occupy a vanguard place among the causes of death in the world today.
Pulmonary Emphysema is also the only major pathology that increases in morbidity and mortality.

 

Cigarette Smoking

Clinical and statistical studies coincide on the fact that Pulmonary Emphysema correlates with cigarette-smoking habit, with the number of cigarettes smoked every day and with the number of years smoking. This symbolises an arithmetical progression. These observations have permitted to show cigarette smoking as a "risk factor".
This benevolence in classifying cigarette smoking simple as a risk factor carry on, implicitly a lack of knowledge about the real respiratory mechanics as an autonomic viscera that performs its own mechanics, as I have demonstrated and interpreted apart.

We know now that the specific respiratory structure of the lung, the lobuli, responds to Sympathetic nerve discharges, to Adrenaline and administration of mimetic drugs. Lets think now about the NICOTINE contained in each cigarette and, bear in mind that Nicotine is pharmacologically well known as a potent Adrenergic positive drug.
Also think about optimal conditions offered by cigarette smoking to produce a sustained and prolonged action and, you yourself will single out cigarette smoking as a causal factor of Pulmonary Emphysema in individuals addicted to this habit. Please sum to this the great amount of involuntary smokers, which simply smoke the environmental smoke containing Nicotine in suspension.

What was mechanically destroyed so remains, The structural damage that characterises Emphysema, such as distension first and break down of elastic and other structures then, are irreversible or of low recuperation.
To give up the habit of smoking means to stop progress of clinical and anatomo-pathologic damages. That worth enough!

 

Prevention

Nevertheless, prevention of Pulmonary Emphysema is not a mere possibility now, it is a fact easy to conquer, and it is a social obligation.

What to do to protect adolescents and young people which aboard the vehicle on direct way to Emphysema in early age?
Does it worth enougth the supposed enjoy of imitation or to let be conquered? To fill like a man and smoke with them?
This means an ignored suicide, slow but sure and not tranquil because the progressive respiratory insufficiency that it carries on, which is restrictive of the beauty of every day life.

I ask young people not to see themselves only in their present age, that look they themselves portrayed as an adult smoker, with emphysema, when arriving that age.

Each one elaborates its own answer. I simply will to suggest everyone my recommendation, NO SMOKING! Self-abstention. Will! For adults. Compulsive prohibition for adolescent and younger with explanation of the why of such prohibition. One argument could be that as they receive free education as a right, they must protect themselves by smoke abstention, since they must preserve their integral health, required for study and development of a discursive mind.

I claim from those responsible for Defence of Human Rights. Health prevention. Education al all levels, to gather efforts to eradicate this terrible pathology, what is very easy from now on since we know now the cause and process.

Another important suggestion is to review concerned traditional concepts about our organisms, as the best and ease method to guarantee prevention in health.

 

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