I.

INTRODUCTION

Equipping oneself with knowledge about various kinds of diseases is a necessity in nursing profession, as this may help enhance the nurse’s ability to promote, restore and maintain health and even prevent occurrence of illness. Each case is unique in its own way though they all possess a particular characteristic, which is to impair a person’s health. Nurses should be knowledgeable in terms of preventing and giving proper intervention with those people who have a specific disease. And one of many different ways in gaining more knowledge is through constant learning and discovery. This case study is a tool in expanding knowledge about a particular disease that will help us in dealing with our future patients. You would think that in the light of modern medical treatment and wide availability of antibiotics, Pneumonia would no longer kill us, right? Wrong! For children, this remains to be a major killer, either as a sole disease beginning with a respiratory infection, or as a complication of measles. Based on DOH (Department of Health) in the Philippines, pneumonia ranked 5th in the leading cause of mortality as of 2006. With these, it is better to understand what really the meaning of this disease is. 1. Description of the disease Pneumonia is basically the infection of the lung which is considered to be a sterile field. This is caused by bacteria, virus and other microorganisms that invade the lungs but most often, pneumonia is caused by bacteria particularly the Streptococcus pneumoniae. Another is that, it is an inflammatory process in the lung parenchyma associated with a marked increase in interstitial and alveolar fluid. This inflammatory process is now 1

treated with antibiotic therapy which led to the perception that this condition is no longer a major problem. In spite of this, pneumonia and influenza are currently the sixth most common cause of death for all ages and one of the most common causes in adult. This condition is also seen among individuals who have weak immune system. As the microorganisms penetrate and invade the lungs, in this condition, the following manifestations may be evident- there is coughing, fever and chills are also evident in relation to the inflammatory process, sweats, pleuritic chest pain, sputum production, hemoptysis in severe cases, dyspnea, headache and fatigue may also be present. Lung diseases have always been a major concern in the health field. In an article in the Jan. 15 issue of the American Journal of Respiratory Critical Care Medicine, there has been this research that a serious life-threatening form of pulmonary fibrosis called idiopathic pulmonary fibrosis. There are certain conditions associated with lung diseases that are barely understood. This diagnosis of the diseases needs the diagnostic procedure which is lung biopsy. However, there is this problem in its feasibility. Not all people with the lung disease can have lung biopsy and this leads to the misdiagnosis of the patients having the condition and receive the wrong treatment and medication. Corticosteroids were the alternatives in treating the disease condition but it has been found out, that corticosteroids are not the solution for all the lung diseases because not all conditions exhibit inflammation and this drug too causes immunosuppression for patients who use this medication making them more susceptible in acquiring different infections present in the environment. With this event, there is this new way of diagnosing the said disease. This is called the DNA Microarray Chip technology. This distinguishes the gene

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expression patterns of several types of interstitial lung diseases. With this new technology, the diagnosis of the different poorly understood lung diseases would be clear now and through this, right diagnosis and prescribed medication will lead to the wellness of the individual. The success of the use of this advancement would now provide a basis for the design of drugs specific to treat the said lung conditions. With this method, it has been found out that idiopathic pulmonary fibrosis is characterized by the increased expression of genes involved in the re-growth of lung tissue and has been found out that it is not an inflammatory condition as it was perceived before. As members of the health team, nurses play an important role in caring for patients with this kind of disease. It is a necessity to have skills in accurately assessing the client's signs and symptoms for a definite diagnosis and appropriate treatments to follow. It is essential to have a knowledge base of gallbladder disease when providing quality care to these patients and attend to their needs. People should be open minded because it should be taken seriously because of the life-threatening effects that may lead to DEATH. This study will help us know more about the etiologic factors, preventive measures in order to combat these pathologic conditions. This case study covers the anatomy and physiology of Pneumonia. It also includes the pathophysiology in relation with the patient which can give information not only for us nurses but also for those people who are aware and unaware of their health. This is one way of achieving and providing the necessary care for our future patients, whether here in the Philippines or elsewhere around the world. The researchers decided to choose Pneumonia as their Case Study due to the fact that this disease has a very high incidence rate both here in the Philippines and in the

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United States. It is also considered as one of the top five dangerous diseases among developing countries. The statistics says it all, with this, the group became interested about the disease. Ergo, as young, vibrant and knowledge seeking student nurses, we have the responsibility to take advantage of learning in detail such type of disease, explore its pathologic process, unravel its complications in order for them to provide pertinent information not only to their fellow student nurses but also to their patients as well. Also, it is but our duty to provide appropriate Nursing Interventions to be done in managing the disease for us to provide quality nursing care with TLC and provide health teachings to the patient on how to prevent further complications for this matter to be handled well enough.

II.

STATISTICS (GLOBAL) COUNTRY USA CANADA AUSTRIA GERMANY FRANCE ITALY SPAIN UK CHINA INCIDENCE 5,132,154 573,668 144,260 1,454,551 1,066,309 1,074,543 710,837 1,063,600 22,920,840 POPULATION 243,665,405 32,507,874 8,174,762 82,424,609 60,424,213 58,057,477 40,280,780 60,270,708 1,298,847,624 4

INDIA INDONESIA JAPAN MALAYSIA PHILIPPINES

18,795,363 4,207,993 2,247,052 415,102 1,521,912

1,065,070,607 238,452,952 127,333,002 23,522,482 86,241,697

MORTALITY: TEN LEADING (10) LEADING CAUSES Number and rate/100,000 Populatio 5-Year Average (2000-2004) & 2005 n Philippines Cause 5 Year Average (2000-2004) Number Rate 2005* No. Rate 90.4 63.8 48.9 42.8 39.1 31.2 24.6 21.6 14.5 3.6 Number and rate/100,000 Populatio 5-Year Average (2000-2004) & 2005 in Philippines 5 Year Average (20002004) No. Rate 694,209 669,800 726,211 459,624 314,175 109,369 43,945 35,970 79,236 15,383 854.7 928.3 587.0 400.5 139.7 56.2 46.1 41.1 19.6

1. Diseases of the Heart 66,412 83.3 77,060 2. Diseases of the Vascular system 50,886 63.9 54,372 3. Malignant Neoplasm 38,578 48.4 41,697 4. Pneumonia 32,989 41.4 36,510 5. Accidents 33,455 42.0 33,327 6. Tuberculosis, all forms 27,211 34.2 26,588 7. Chronic lower respiratory 18,015 22.6 20,951 diseases 8.Diabetes Mellitus 13,584 17.0 18,441 9. Certain conditions originating in 14,477 18.2 12,368 the perinatal period 10. Nephritis, nephrotic syndrome 9.166 11.5 11,056 and nephrosis MORBIDITY: TEN LEADING (10) LEADING CAUSES

CAUSE 1. Acute Lower RTI and Pneumonia 2. Bronchitis/ Bronchiolitis 3. Acute Watery Diarrhea 4. Influenza 5. Hypertension 6. TB Respiratory 7. Diseases of the Heart 8. Malaria 9. Chickenpox 10. Dengue Fever

2005* No. Rate 809.9

884.6 690,566

616,041 722.5 603,287 707.6 406,237 476.5 382,662 448.8 114,360 134.1 43,898 51.5 36,090 42.3 30,063 35.3 20,107 23.6

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Nurse-Centered Objectives: As the case study progresses, the group aim to achieve the following objectives: • To broaden our knowledge and heighten our background about the disease condition. • Define the disease condition; its signs and symptoms, understand risk factors, pathophysiology, and its underlying complications. • To determine the manifestations and complication that might develop to prevent from occurrence and know the basic intervention needed for the disease. • To provide quality-nursing care by setting specific goals and appropriate nursing intervention which are essential to the client’s condition. • To supplement health teachings to the client especially factors that will contribute to the continuity of care.

III. NURSING HISTORY

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1. PERSONAL HISTORY Mr. Sapatero a 58 years old male patient was born on May 24,1958 at Dolores Mabalacat Hospital? He is a Filipino Catholic citizen currently living at 1318 Carolina St., Villasol, Friendship Angeles City. He was married to his wife Mrs. Kulotera, and is the head of the family. They have four children;

Mr. Sapatero is an undergraduate of accountancy at HAU, he was not able to pursue his studies due to financial constraint. According to him, their monthly expenses are supported by her daughters who are working in Japan. His wife narrated that her husband’s favorite food are mongo and lamang loob ng chicken, especially the intestines of chicken. When it comes to their health, Mr. Sapatero prefers to consult a doctor rather than going to an”albularyo”, but despite of that they use herbal medications.

2. FAMILY-HEALTH ILLNESS HISTORY

Mr. Sapatero’s father was diagnosed with Tuberculosis, after quite sometime his mother also experienced symptoms of Tuberculosis and diagnosed with the same disease. According to MR. Sapatero’s father, his grandmother was busy cleaning their backyard when suddenly a bicycle accidentally hit her and she fell over the drainage and she was then sent to the hospital, the doctor then said that she will bee in the state of comatose. After a month his grandmother died.

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3.) HISTORY OF PAST ILLNESS Mr. Sapatero’s favorite sport was bowling and tennis, when he was working abroad, he played basketball with his workmates, then his left foot was sprained because he was accidentally hit by his playmate. He ignored hiw sprain and took it for granted.

4.) HISTORY OF PRESENT ILLNESS

Mr. Sapatero had a chief complaint of body weakness 1 week prior to admission and a diagnosis of Gouty Arthitis.

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Legend:

Grandfather

Uncle

Mother

Grandmother

Father

Client

Deceased Hypertensive

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Based from the above diagram, on the mother side, they don’t have any history of diseases. On the father side, her Grandfather died because of exposure to chemicals. Four of her uncles are hypertensive. Baby G is the only person in their family who have this kind of disease. 3. PERSONAL HISTORY During Mrs. Y pregnancy with Baby G she has completed her regular once a month check-up. Even though she is pregnant, she was still doing household chores. She just stopped doing household chores prior to her delivery. When she was pregnant, she was not drinking vitamins but instead, she drinks milk and eat fruits and vegetables. She gave birth on December 11, 2008 at Balitucan District Hospital through NSD, preterm. Mrs. Y started to experience labor pain by 6:00 am and by 8:15 am she delivered a baby girl weighing 3.5kgs. She did not experienced pregnancy induced hypertension and other complications of pregnancy. Bottle feeding was introduced to Baby G upon birth and up to now. GROWTH AND DEVELOPMENT Erik Erickson Psychosocial Stage Baby G who is currently 8th months old is under Trust vs. Mistrust Stage of Erik Erickson’s Psychosocial Stage (0-1 y/o). During this stage, it is normal for a child to have what we call “stranger anxiety”. According to Mrs. Y, Baby G frowns and cries every time she tries or she attempts to carry her. Gaining the trust of Baby G was not difficult, but she only wanted her mother or

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her father to carry him. It was hard assessing Baby G because he was sometimes irritated and uncomfortable being touches by others. Sigmund Freud Psychosexual Stage Baby G falls under the Oral Stage of Sigmund Freud Psychosexual Stage (0-18 mos.). At this time, oral activity gives pleasure to the child. The child seeks enjoyment or relief of tension, as well as for nourishment. The child meets the world orally by crying, tasting and early vocalizing. And the child uses grasping and touching to explore variations in the environment. To satisfy this need, Mrs. H provided oral stimulation by wetting the lips using wet cottons especially when the Baby G was put on NPO. Jean Piaget Cognitive Development Baby G falls under the Sensorimotor Stage of Jean Piaget’s Cognitive Development (018mos.). Baby G falls under the substage 3 (4 to 8 mos.). During this time, the child acquired adaptation and a shifting of attention to objects and the environment. This was proven when Baby G touches the objects she saw in the crib, she grasped them and did some manipulation. IMMUNIZATION STATUS Baby H has a complete immunization status. BCG was given December 18, 2009 when he was 1 week old. DPT, OPV and Hepatitis B were given on his sixth month, June 2009. The measles vaccine is scheduled this coming September 11, 2009. 4. HISTORY OF PAST ILLNESS Baby G frequently experienced cough and colds and fever, usually twice a month. All of these were treated by using over the counter drugs and some herbal medicines at home.

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5. HISTORY OF PRESENT ILLNESS Baby G experienced cough and colds, and on and off fever eight days prior to admission. Four days prior to confinement she experienced cough and colds with phlegm. All of these were treated when she was admitted at Balitucan District Hospital. And few hours prior to confinement she experienced difficulty of breathing and consulted at PMD; chest x-ray was done revealing pneumothorax, hence transferred to JBLMRH.

6. PHYSICAL EXAMINATION (IPPA-PSA Cephalocaudal Approach) August 24, 2009 – Admission PE Skin:  pinkish  (-) cyanosis HEAD  EENT- anicteric sclera - pale palpebral conjunctiva CHEST  LUNGS- symmetrical chest expansion - (+) rales and retractions Lymph nodes:  (-) lymphadenophaty Abdomen: • flat with normal bowel sounds Rectum: • (+) patent August 27, 2009 Received pt. lying in crib, vital signs was taken as follows: T= 37°C PR=104 bpm RR=96 bpm. Hair: ♥ hair is thin ♥ black in color ♥ silky and resilient 12

♥ no notable presence of infestation Head and Skull: ♥ head is rounded and symmetric ♥ smooth skull contour, no nodules or masses ♥ no lesions noted Eyes: ♥ eyebrows and eyelashes are black in color ♥ evenly distributed ♥ eyebrows symmetrically aligned ♥ no discharge ♥ anicteric sclerae ♥ pink palpebral conjunctiva ♥ PERRLA Ears: ♥ ♥ ♥ ♥ ♥ brown in color symmetrical auricle aligned with outer canthus of the eye firm and not tender no foul smelling discharges

Nose: ♥ symmetric ♥ no discharge ♥ (+) nasal flaring ♥ not tender; no lesions Mouth: ♥ lips are dry ♥ pink gums; no retraction ♥ tongue is centered ♥ moist, smooth and soft ♥ no tenderness Heart/Chest: ♥ chest has a normal contour ♥ symmetrical chest expansion ♥ no tenderness and masses ♥ RR= 96

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Lungs: ♥ diminished breath sounds on right lung field Abdomen: ♥ flat ♥ normal, abdominal bowel sounds ♥ no abnormal findings upon percussion ♥ no masses found upon palpation Extremities: ♥ fingernails and toenails are of normal curve ♥ no presence of abnormal discoloration ♥ smooth in texture ♥ has a normal capillary refill of less than 2 seconds Skin: ♥ with fair complexion ♥ no cyanosis ♥ no pallor ♥ no edema and lesions noted ♥ has good skin turgor (skin pinch returns to normal within 1-2 seconds) August 28, 2009 Received pt. lying in crib, vital signs was taken as follows: T= 37.8°C PR=96 bpm RR=92 bpm. Hair: ♥ hair is thin ♥ black in color ♥ silky and resilient ♥ no notable presence of infestation Head and Skull: ♥ head is rounded and symmetric ♥ smooth skull contour, no nodules or masses ♥ no lesions noted Eyes: ♥ eyebrows and eyelashes are black in color ♥ evenly distributed ♥ eyebrows symmetrically aligned ♥ no discharge 14

♥ anicteric sclerae ♥ pale palpebral conjunctiva ♥ PERRLA Ears: ♥ ♥ ♥ ♥ ♥ brown in color symmetrical auricle aligned with outer canthus of the eye firm and not tender no foul smelling discharges

Nose: ♥ symmetric ♥ no discharge ♥ (+) nasal flaring ♥ not tender; no lesions Mouth: ♥ lips are dry ♥ pink gums; no retraction ♥ tongue is centered ♥ moist, smooth and soft ♥ no tenderness Heart/Chest: ♥ chest has a normal contour ♥ symmetrical chest expansion ♥ no tenderness and masses ♥ RR=92 Lungs: ♥ diminished breath sounds on right lung field Abdomen: ♥ flat ♥ normal, abdominal bowel sounds ♥ no abnormal findings upon percussion ♥ no masses found upon palpation Extremities: ♥ fingernails and toenails are of normal curve ♥ no presence of abnormal discoloration ♥ smooth in texture 15

♥ has a normal capillary refill of less than 2 seconds Skin: ♥ with fair complexion ♥ no cyanosis ♥ no pallor ♥ no edema and lesions noted ♥ has good skin turgor (skin pinch returns to normal within 1-2 seconds)

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7. DIAGNOSTIC AND LABORATORY PROCEDURES

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DIAGNOSTIC LABORATORY PROCEDURES Complete Blood Count Hemoglobin

DATE ORDERED DATE RESULT(S) IN

INDICATIONS OR PURPOSE

RESULTS

NORMAL ANALYSIS VALUES AND ( UNITS USED IN INTERPRETAT THE HOSPITAL) ION OF RESULTS

D.O:08-24-09 D.R:08-24-09

It measures the total amount of hemoglobin in the blood, to determine the O2 carrying capacity of the blood. It measures the percentage of RBCS in the total blood volume. It determines the number of circulating WBCS of the whole blood. Phagocytes present in the circulation or along the capillary walls.

114g/l

( 125-175g/l)

The result is below normal values, which is a symptom of having an anemia. There was slight decrease in the results due to hemodilution. The result is within normal values. The result is above normal value indicating that there is bacterial or parasitic infection. The result is within normal values. The result is within normal 18 values. The result is

Hematocrit

D.O:08-24-09 D.R:08-24-09 D.O:08-24-09 D.R:08-24-09

0.33

(0.40- 0.52)

Leukocytes (WBC)

7.2

(5-10 x 10g/l)

Neutrophils

D.O:08-24-09 D.R:08-24-09

0.75

(0.45-0.65)

Lymphocytes

D.O:08-24-09 D.R:08-24-09

Produces antibodies responsible for allergic reactions. Have phagocytic action by removing dead and injured cells, cell fragments and microorganisms. To evaluate platelet production, to monitor and diagnose severe

0.25

(0.20-0.35)

Monocytes

D.O:08-24-09 D.R:08-24-09

0.04

(0.0 2-0.06)

Platelet Count

D.O:08-24-09

846

(150-400x10g/l)

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NURSING RESPONSIBILITIES Prior:  Check for the doctor’s order, verify the patient.  Explain to the patient the purpose of these tests.  Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.  Explain to the patient that he may feel slight discomfort from the tourniquet and the needle puncture.  Tell the patient that no fasting is required. During:  Tell the patient when to insert the needle for her to be prepared.  Encourage the patient to remain calm during the test.  Assist the patient if necessary/  Ensure a sterile blood sample from the patient.  Collect approximately 5 to 7ml of venous blood in the bottle.  Avoid hemolysis. After:

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 After completely filling the collection tube, invert it gently several times to thoroughly mix the sample and the anticoagulant.  Label properly and send the sample to the laboratory immediately.  Handle the sample gently to prevent hemolysis.  Apply direct pressure to the venipuncture site, until bleeding stops  If large hematoma develops at the venipuncture site, monitor pulses distal to the site.

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DIAGNOSTIC LABORATORY PROCEDURES Chest Xray

DATE ORDERED DATE RESULT(S) IN

INDICATIONS OR PURPOSE

RESULTS

NORMAL ANALYSIS VALUES AND ( UNITS USED IN INTERPRETAT THE HOSPITAL) ION OF RESULTS

Chest X-ray - Commonly ordered laboratory examination.

Date ordered: 08-24-05 Date performed: 08-24-05

Chest X-ray -it is used in the diagnosis of pulmonary diseases and provides important information concerning the status of heart, gastrointestinal tract, thyroid gland, bones of the thorax

Radiographic Report -The right hemidiaphragm No abnormalities of appears intact. No lungs, pleura, definite evidence of thorax, soft tissues, opening atelectasis vs, mediastinum, heart, consolidation is seen and aortic arch in the right costophrenic angle, the rest of the right hemithorax contains air (possible pneumothorax)

The results indicate that the patient has possible pneumothorax due to air in the right hemithorax.

NURSING RESPONSIBILITIES Prior:  Explain the procedure to the patient

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 Tell the patient that no fasting is required.  Instruct the patient to remove clothing to the waist and to put on an x-ray gown.  Inform the pt to remove all metal objects (e.g. neck, faces, pins) so that they do not block visualization of part of the chest  Tell the patient that he will be asked to take a deep breath and hold it wile the x-ray films are taken. During:  After the patient is correctly positioned, tell him to take a deep breath and hold it until the x-ray films are taken by a radiologic technologist several minutes.  Inform the patient the no discomfort is associated with chest radiography After:  Note that no special care is required following the procedure.

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III. ANATOMY AND PHYSIOLOGY Respiratory System I. Introduction

Respiratory System, in anatomy and physiology, comprises of organs that deliver oxygen to the circulatory system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular activities. In addition to supplying oxygen, the respiratory system aids in removing of carbon dioxide, preventing the lethal buildup of this waste product in body tissues. Day-in and day-out, without the prompt of conscious thought, the respiratory system carries out its lifesustaining activities. If the respiratory system’s tasks are interrupted for more than a few minutes, serious, irreversible damage to tissues occurs, followed by the failure of all body systems, and ultimately, death. 24

While the intake of oxygen and removal of carbon dioxide are the primary functions of the respiratory system, it plays other important roles in the body. The respiratory system helps regulate the balance of acid and base in tissues, a process crucial for the normal functioning of cells. It protects the body against disease-causing organisms and toxic substances inhaled with air. The respiratory system also houses the cells that detect smell, and assists in the production of sounds for speech. The respiratory and circulatory systems work together to deliver oxygen to cells and remove carbon dioxide in a two-phase process called respiration. The first phase of respiration begins with breathing in, or inhalation. Inhalation brings air from outside the body into the lungs. Oxygen in the air moves from the lungs through blood vessels to the heart, which pumps the oxygen-rich blood to all parts of the body. Oxygen then moves from the bloodstream into cells, which completes the first phase of respiration. In the cells, oxygen is used in a separate energy-producing process called cellular respiration, which produces carbon dioxide as a byproduct. The second phase of respiration begins with the movement of carbon dioxide from the cells to the bloodstream. The bloodstream carries carbon dioxide to the heart, which pumps the carbon dioxide-laden blood to the lungs. In the lungs, breathing out, or exhalation, removes carbon dioxide from the body, thus completing the respiration cycle. II. Structure The organs of the respiratory system extend from the nose to the lungs and are divided into the upper and lower respiratory tracts. The upper respiratory tract consists of the nose and the pharynx, or throat. The lower respiratory tract includes the larynx, or voice box; the trachea, or windpipe, which splits into two main branches called bronchi;

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tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike, spongy organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and from the lungs. The lungs interact with the circulatory system to deliver oxygen and remove carbon dioxide. A. Nasal Passages

Anatomy of the Nose The uppermost portion of the human respiratory system, the nose is a hollow air passage that functions in breathing and in the sense of smell. The nasal cavity moistens and warms incoming air, while small hairs and mucus filter out harmful particles and microorganisms. The flow of air from outside of the body to the lungs begins with the nose, which is divided into the left and right nasal passages. The nasal passages are lined with a membrane composed primarily of one layer of flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with thousands of microscopic cilia, 26

fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the mucous membrane, near the surface of the nasal passages. While transporting air to the pharynx, the nasal passages play two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system. Filtering prevents airborne bacteria, viruses, other potentially disease-causing substances from entering the lungs, where they may cause infection. Filtering also eliminates smog and dust particles, which may clog the narrow air passages in the smallest bronchioles. Coarse hairs found just inside the nostrils of the nose trap airborne particles as they are inhaled. The particles drop down onto the mucous membrane lining the nasal passages. The cilia embedded in the mucous membrane wave constantly, creating a current of mucus that propels the particles out of the nose or downward to the pharynx. In the pharynx, the mucus is swallowed and passed to the stomach, where the particles are destroyed by stomach acid. If more particles are in the nasal passages than the cilia can handle, the particles build up on the mucus and irritate the membrane beneath it. This irritation triggers a reflex that produces a sneeze to get rid of the polluted air. The nasal passages also moisten and warm air to prevent it from damaging the delicate membranes of the lung. The mucous membranes of the nasal passages release water vapor, which moistens the air as it passes over the membranes. As air moves over the extensive capillaries in the nasal passages, it is warmed by the blood in the capillaries.

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If the nose is blocked or “stuffy” due to a cold or allergies, a person is forced to breath through the mouth. This can be potentially harmful to the respiratory system membranes, since the mouth does not filter, warm, or moisten air. In addition to their role in the respiratory system, the nasal passages house cells called olfactory receptors, which are involved in the sense of smell. When chemicals enter the nasal passages, they contact the olfactory receptors. This triggers the receptors to send a signal to the brain, which creates the perception of smell. B. Pharynx Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. In addition to serving as an air passage, the pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages and pharynx. The tonsils are strategically located to prevent these organisms from moving further into the body. One tonsil, called the adenoids, is found high in the rear wall of the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of the pharynx on either side of the tongue. Another pair, the lingual tonsils, is found deep in the pharynx at the base of the tongue. In their battles with disease-causing organisms, the tonsils sometimes become swollen with infection. When the adenoids are swollen, they block the flow of air from the nasal passages to the pharynx, and a person must breathe through the mouth.

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C. Larynx Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. A protrusion in the cartilage called the Adam’s apple sometimes enlarges in males during puberty, creating a prominent bulge visible on the neck. While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and ciliabearing cells help filter air. The cilia in the larynx waft airborne particles up toward the pharynx to be swallowed. 29

Food and fluids from the pharynx usually are prevented from entering the larynx by the epiglottis, a thin, leaflike tissue. The “stem” of the leaf attaches to the front and top of the larynx. When a person is breathing, the epiglottis is held in a vertical position, like an open trap door. When a person swallows, however, a reflex causes the larynx and the epiglottis to move toward each other, forming a protective seal, and food and fluids are routed to the esophagus. If a person is eating or drinking too rapidly, or laughs while swallowing, the swallowing reflex may not work, and food or fluid can enter the larynx. Food, fluid, or other substances in the larynx initiate a cough reflex as the body attempts to clear the larynx of the obstruction. If the cough reflex does not work, a person can choke, a life30

threatening situation. The Heimlich maneuver is a technique used to clear a blocked larynx (see First Aid). A surgical procedure called a tracheotomy is used to bypass the larynx and get air to the trachea in extreme cases of choking. D. Trachea, Bronchi, and Bronchioles

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6 in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the “C” are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles

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contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx. E. Alveoli The bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence helps ensure that the alveoli are protected from infection so that they can carry out their vital role.

Human Lungs Though the right lung has three lobes, the left lung, with a cleft to accommodate the heart, has only two. The two branches of the trachea, called bronchi, subdivide within 32

the lobes into smaller and smaller air vessels. They terminate in alveoli, tiny air sacs surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses into the blood in the capillaries to be pumped by the heart to the tissues of the body, and carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.

The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli resemble tiny, collapsed balloons with thin elastic walls that expand as air flows into them and collapse when the air is exhaled. Alveoli are arranged in grapelike clusters, and each cluster is surrounded by a dense hairnet of tiny, thin-walled capillaries. The alveoli and capillaries are arranged in such a way that air in the wall of the alveoli is only about 0.1 to 0.2 microns from the blood in the capillary. Since the concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the alveoli to the capillaries. The oxygen flows through the capillaries to larger vessels, which carry the oxygenated blood to the heart, where it is pumped to the rest of the body. Carbon dioxide that has been dumped into the bloodstream as a waste product from cells throughout the body flows through the bloodstream to the heart, and then to the alveolar capillaries. The concentration of carbon dioxide in the capillaries is much higher than in the alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation forces the carbon dioxide back through the respiratory passages and then to the outside of the body. III. Regulation The flow of air in and out of the lungs is controlled by the nervous system, which ensures that humans breathe in a regular pattern and at a regular rate. Breathing is carried

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out day and night by an unconscious process. It begins with a cluster of nerve cells in the brain stem called the respiratory center. These cells send simultaneous signals to the diaphragm and rib muscles, the muscles involved in inhalation. The diaphragm is a large, dome-shaped muscle that lies just under the lungs. When the diaphragm is stimulated by a nervous impulse, it flattens. The downward movement of the diaphragm expands the volume of the cavity that contains the lungs, the thoracic cavity. When the rib muscles are stimulated, they also contract, pulling the rib cage up and out like the handle of a pail. This movement also expands the thoracic cavity. The increased volume of the thoracic cavity causes air to rush into the lungs. The nervous stimulation is brief, and when it ceases, the diaphragm and rib muscles relax and exhalation occurs. Under normal conditions, the respiratory center emits signals 12 to 20 times a minute, causing a person to take 12 to 20 breaths a minute. Newborns breathe at a faster rate, about 30 to 50 breaths a minute. The rhythm set by the respiratory center can be altered by conscious control. The breathing pattern changes when a person sings or whistles, for example. A person also can alter the breathing pattern by holding the breath. The cerebral cortex, the part of the brain involved in thinking, can send signals to the diaphragm and rib muscles that temporarily override the signals from the respiratory center. The ability to hold one’s breath has survival value. If a person encounters noxious fumes, for example, it is possible to avoid inhaling the fumes. A person cannot hold the breath indefinitely, however. If exhalation does not occur, carbon dioxide accumulates in the blood, which, in turn, causes the blood to become more acidic. Increased acidity interferes with the action of enzymes, the

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specialized proteins that participate in virtually all biochemical reaction in the body. To prevent the blood from becoming too acidic, the blood is monitored by special receptors called chemoreceptors, located in the brainstem and in the blood vessels of the neck. If acid builds up in the blood, the chemoreceptors send nervous signals to the respiratory center, which overrides the signals from the cerebral cortex and causes a person to exhale and then resume breathing. These exhalations expel the carbon dioxide and bring the blood acid level back to normal. A person can exert some degree of control over the amount of air inhaled, with some limitations. To prevent the lungs from bursting from overinflation, specialized cells in the lungs called stretch receptors measure the volume of air in the lungs. When the volume reaches an unsafe threshold, the stretch receptors send signals to the respiratory center, which shuts down the muscles of inhalation and halts the intake of air.

Diaphragm and Respiration

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As the diaphragm contracts and moves downward, the pectoralis minor and intercostal muscles pull the rib cage outward. The chest cavity expands, and air rushes into the lungs through the trachea to fill the resulting vacuum. When the diaphragm relaxes to its normal, upwardly curving position, the lungs contract, and air is forced out.

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