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Morphologic Determinants of Asphyxia in Lungs

A Semiquantitative Study in Forensic Autopsies
Carlos Delmonte, M.D., Ph.D., and Vera Luiza Capelozzi, M.D., Ph.D.
From the Forensic Institute of Medicine (C.D.) and Department
of Pathology (V.L.C.), University of So Paulo School of
Medicine, So Paulo, Brazil.
Disusun Oleh :
Cut Lamia Isnaini
Elda Maharani
Ridha Mawaddah
Pembimbing:
Dr.dr.H.Taufik Suryadi,Sp.F
BAGIAN/SMF FORENSIK
FAKULTAS KEDOKTERAN UNIVERSITAS SYIAH KUALA
BLUD RSUD Dr. ZAINOEL ABIDIN
BANDA ACEH
ABSTRACT
Asphyxia is a name given to different kinds of lesions that can produce
similar histologic findings. Thus, because of the varied nature of the different
kinds of lesions, as well as the incidence of similar qualitative histologic
findings with different causes, the aim of this work was to study special
kinds of injuries with particular subsequent impairment. These include some
diagnostic problems of sudden death of natural causes, including aspiration,
suffocation, drowning, and strangulation.
Lung autopsies with congestion, septal hemorrhage, and foreign body
showed a specificity of 100% for victims of aspiration, where as ductal
overinsufflation, interstitial edema, and bronchiolar constriction showed a
specificity of 81.8% in victims of suffocation. Intraalveolar edema and
dilatation of the alveolar spaces with secondary compression of the septal
capillaries characterized drowning. Victims of strangulation showed a strong
alveolar hemorrhage, with alveolar collapse and overinsufflation, associated
with bronchiolar dilatation. It is concluded that semiquantitative analysis of
lung autopsies might be a useful supplementary histologic criterion to
support the diagnosis of asphyxia.
INTRODUCTION
In biologic systems, the extent and type of pathologic and toxicologic findings can
often be correlated with the specific circumstances of the fatal event.
it is important to document the pathologic changes in such cases to exclude other
forms of trauma or other modes of death that may denote murder made to appear as
suicide or natural death.
it appears to us that subtle differences n the particular constellation of histopathologic
changes within the asphyxia death category may reflect how death occurred, through
a gradation and quantitation of pathophysiologic alterations based on both the rapidity
of compromise of the respiratory tract and its degree of completeness.
the aim of this work was to determine semiquantitative morphologic parameters in
previous demographic and circumstantial data in 167 consecutive asphyxia deaths by
aspiration, suffocation, drowning, and strangulation investigated by the Forensic
Institute of Medicine in So Paulo.
METHODS
Demographic and Situational Data
The deaths included in this study consisted of 200 cases
consecutively investigated from 1996 to 1998 by the
Forensic Institute of Medicine (Table 1)
Technical Procedures to Obtain the Lungs

The thoracotomy was done in the anterior medial line
by sternopubic incision.
Multi-agent
Regimen
METHODS
Morphologic Study
1. Qualitative Analysis (Figure 1,2,3,4)
2. Quantitative Analysis
Statistical Analysis
All statistical procedures were done by use of
the SPPS (version 6.0) statistical package (9),
and the level of significance was 0.5%.
FIG.1
Lung parenchyma
in asphyxia by
suffocation.
(AD) Alternating
zones of ductal
overinsufflation
(ov) and alveolar
collapse (col) of
the
lung
parenchyma
in
suffocation cases.
(B,D)
Characteristic
interstitial edema
(ed).
FIG. 2. Lung
parenchyma in
strangulation
(suicidal hanging and
homicidal ligature
strangulation).
(A,B) Intraalveolar
hemorrhage (hem).
(CF) Alternating areas
of alveolar collapse (col)
and overinsufflation (ov).
(G,H) Zones of
bronchiolar constriction
(brc) and dilatation (brd),
a characteristic
morphologic picture in
this group.
FIG. 3. Lung
parenchyma in
drowning cases.
(A) Panoramic view of
intraalveolar deposition of
proteic and amorphous
material (am).
(B) High-magnification
view showing acute
dilatation of the alveoli
with extension,
elongation, and thinning
of the septa and
compression of the
alveolar capillaries by a
prominent intraalveolar
reddish liquid similar to
edema (am).
FIG. 4. Lung
parenchyma in
aspiration cases.(
AD) Characteristic
histologic appearance
of congestion areas
(cong) and engorged
capillaries protruding into
the alveolar lumen
(arrows), as well as the
foreign body occupying
the bronchiolar and
alveolar lumen
(arrowheads).
(E,F) Septal
hemorrhage
(double arrows), a typical
morphologic reaction
finding in this.
METHODS
Quantitative Analysis
These parameters were semiquantified by a histopathologic
score according to the extent and severity of the histopathologic
lesions present in total tissue, examined as follows:
0: Absence of lesion
1: Presence of lesions in 1% to 25%
RESULT
Aspiration
Congestion and hemorrhage allowed a distinctive histologic pattern to be highly associated with
a diagnosis of aspiration, in which a septal hemorrhage was the typical morphologic reaction In
addition to this picture of hemorrhage, there was considerable foreign body occupation of the
lumen of the bronchioles and alveoli . Thirty aspiration victims (100%) were properly classified
as having aspiration
Suffocation
In the second pattern of asphyxia, the extension of the area occupied by
ductal overinsufflation. and interstitial edema, were statistically more frequent
in suffocation than in drowning or strangulation. However, ductal
overinsufflation in the form of acute substantial emphysema was
characteristically present in most cases of death by suffocation.
Drowning
In the third pattern of asphyxia, extension of the area occupied by intraalveolar deposition of
proteic and amorphous material, was the semiquantitative parameter statistically associated
with drowning. The other parameters, although still present, were not as statistically significant
in drowning as the edema was.
Strangulation
The extension of the area occupied by alveolar hemorrhage, was significantly
higher in lungs associated with strangulation. Equally significant was the
association of alveolar collapse, alveolar overinsufflation, and alternating zones
of bronchiolar constriction and bronchiolar dilatation
DISCUSSION
Asphyxia can be defined as the injuries caused by oxygen
deficiency (hypoxia) that involve all conditions and sequelae
caused by impairment or interruption of the oxygen supply or
utilization in the tissues.
In this work, qualitative study revealed common morphologic
parameters for the four groups of asphyxia. In all cases
histologically analyzed, the pulmonary architecture showed
variables in the degree of alveolar tissue collapse, overinsufflation,
bronchiolar constriction, and dilatation.
suffocation in forensic medical usage is restricted, for practical purposes, to cases

in which environmental suffocation (inadequate oxygen in the atmosphere due to
environmental conditions), smothering (due to mechanical obstruction of the nose
and mouth), choking (due to blockage of the internal airways), and mechanical (due
to pressure on the chest)
In addition, the known macroscopic and histologic signs of general damage
through hypoxia, e.g., edema, hemorrhage, pulmonary emphysema, passive
congestion, and degenerative cellular changes, are usually diverse and are not
conclusive as individual findings . Similar findings can also arise through injuries
leading to impairment of the circulation, or ischemia, thereby reducing or interrupting
the tissue oxygen supplies.
DISCUSSION
As aspiration lung was characterized by gastric content or amniotic
fluid, partially or totally filling the bronchiolar lumen and the alveolar
spaces, thus characterizing the foreign material aspirated. As a
consequence, occlusion of the small airways, mainly the
membranous and respiratory bronchioles, was atypical morphologic
finding.
fresh-water drowned lung was characterized by acute dilatation of the alveoli with
extension, elongation, and thinning of by a prominent intraalveolar intense rosecolored liquid similar to edema. Reidbord and Spitz and Spitz et al, described similar
findings in victims drowning in fresh water, and unlike the findings of Knight, these
positive signs of drowning were not scanty and nonspecific. The histopathologic
picture of intraalveolar deposition of proteic and amorphous material (near-edema)
found in fresh-water drowned lung has strong support in experimental studies on rats
involving active aspiration of watery liquids of various osmolarities.
In the fourth group of asphyxia, strangulation, alternating areas of bronchiolar constriction and
dilatation leading to alveolar collapse and overinsufflation, associated with a picture of alveolar
hemorrhage, were the morphologic characteristics of lung involvement. The Hamburg working
group around Brinkmann has systematically studied the pathophysiologic processes that occur in
the pulmonary vascular system and pulmonary tissue during strangulation. The object of these
animal experiments and comparative pathologic studies in humans was the compilation of findings
utilizing histopathologic staining methods and forensic-medical assessments. Further
investigations concerning these problems involve the frequency of pulmonary hemorrhage in
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JOURNAL

Morphologic Determinants of Asphyxia in Lungs

Technical Procedures to Obtain the Lungs

suffocation in forensic medical usage is restricted, for practical purposes, to cases

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