ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM
Respiration has two meanings in biology.
At the cellular level it re!ers to the O" re#uiring chemical reactions that ta$e place in the
mitochon%ria an% are the chie! source o! energy in the eu$aryotic cells.
At the level o! the whole organism it %esignates the process o! ta$ing In O" !rom the
environment an% returning &O" to it.
O" consumptions is %irectly relate% to energy e'pen%iture. Energy re#uirements are usually
calculate% by measuring O" inta$e o! &O" release. Energy e'pen%iture at rest is $nown as
basal metabolism.
(unctional Anatomy o! the Respiratory System
The organs o! the respiratory system inclu%e the nose pharyn' laryn' trachea bronchi an%
their smaller branches an% the lungs which contain the alveoli or terminal air sacs. Since gas
e'changes with the bloo% happen only in the alveoli the other respiratory system structures are
really )ust con%ucting passageways that allow air to reach !or lungs. *owever these
passageways have another important )ob. They puri!y humi%i!y an% warm incoming air. Thus
the air !inally reaching the lungs has many !ewer irritants +such as %ust or bacteria, than when it
entere% the system.
The -ose
The nose is the only e'ternally visible part o! the respiratory system. .uring breathing
air enters the nose by passing through the nostrils or e'ternal nares. The interior the nose
consists o! the nasal cavity %ivi%e% by a mi%line nasal septum. It has three mucosa/covere%
pro)ections or loves calle% conchae which greatly increase the sur!ace area o! the mucosa
e'pose% to the air an% increase the air turbulence in the nasal cavity. It is separate% !rom the
oral cavity below by a partition the palate. Anteriorly where the palate is supporte% by bone is
the har% palate0 the unsupporte% posterior part is the so!t palate. It is surroun%e% by a ring o!
paranasal sinuses locate% in the !rontal sphenoi% ethmoi% an% ma'illary bones which lighten
the s$ull act as resonance chambers !or speech an% pro%uce mucus which %rains into the
nasal cavities.
Pharyn'
The pharyn' +throat, is a muscular passageway about 12cm long that vaguely
resembles a short length o! re% gar%en hose. It serves as a common passageway !or !oo% an%
air an% is continuous with the nasal cavity anteriorly via the internal nares. Air enters the
nasopharyn' !rom the nasal cavity an% then %escen%s through the oropharyn' an%
laryngopharyn' to enter the laryn' below. It consists o! pharyngotympanic tubes which %rain the
mi%%le ear open into the nasopharyn'. &lusters o! lymphatic tissue calle% tonsils are also !oun%
in the laryn'. The pharyngeal tonsil +a%enoi%, is o3locate% high in the nasopharyn'. The
palatine tonsils are in the oropharyn' at the en% o! the so!t palate0 the lingual tonsils are at the
base o! the tongue. These tonsils protect the bo%y !rom in!ection
4aryn'
The laryn' +voice bo', routes air an% !oo% into the proper channels an% plays a role in
speech. It is !orme% by eight rigi% hyaline cartilages an% a spoon/shape% !lap o! elastic cartilage
the epiglottis. The epiglottis protects the superior opening o! the laryn'. I! anything other than
the air enters the laryn' a cough re!le' is triggere% to e'pel the substance an% prevent it !rom
continuing into the lungs. Part o! the mucous membrane o! the laryn' !orms a pair o! !ol%s the
vocal !ol%s or true vocal cor%s which vibrate with e'pelle% air. It then allows us to spea$.
Trachea
Air enters trachea +win%pipe, !rom the laryn' then travels %own its length +15/1"cm, to
the level o! the !i!th thoracic vertebra which is appro'imately mi%chest. It is !airly rigi% because
its walls are rein!orce% with &/shape% rings o! hyaline cartilage which serve a %ouble purpose.
The open parts o! the rings abut the esophagus an% allow it to e'pan% anteriorly when we
swallow a large piece o! !oo%. The soli% portions support the trachea walls an% $eep it patent or
open in spite o! the pressure changes that occur %uring breathing.
Main 6ronchi
The right an% le!t main +primary, bronchi are !orme% by the %ivision o! the trachea. Each
main bronchus runs obli#uely be!ore it plunges into the me%ial %epression +bilus, o! the lung on
its own si%e. The right main bronchus is wi%er shorter an% straighter than the le!t.
&onse#uently it is more common site !or an inhale% !oreign ob)ect to become lo%ge%. 6y the
time incoming air reaches the bronchi it is warm cleanse% o! most impurities an% well
humi%i!ie%. The smaller sub%ivisions o! the main bronchi within the lungs are %irect routes to the
air sacs.
4ungs
The paire% lungs are !airly large organs. They occupy the entire thoracic cavity e'cept
!or the most central area the me%iastinum which houses the heart great bloo% vessels
bronchi esophagus an% other organs. The narrow superior portion o! each lung the ape' is
locate% )ust %eep to the clavicle. The broa% lung area resting on the %iaphragm is the base.
Each lung is %ivi%e% into loves by !issures0 the le!t lung has two lobes an% the right lung has
three. The sur!ace o! each lungs is covere% with a visceral serosa calle% the pulmonary or
visceral pleura an% the walls o! the thoracic cavity are line% by the parietal pleura. The pleural
membranes pro%uce pleural !lui% a slippery serous secretion which allows the lungs to gli%e
easily over the thora' wall %uring breathing movements an% causes the two pleural layers to
cling together. A!ter the primary bronchi enter the lungs they sub%ivi%e into smaller an% smaller
braches +secon%ary an% tertiary bronchi an% so on, !inally en%ing in the smallest o! the
con%ucting passageways the bronchioles. The terminal bronchioles lea% into respiratory 7one
structures even smaller con%uits that eventually terminate in alveoli.
The Respiratory Membrane
The walls o! the alveoli are compose% largely o! a single thin layer o! s#uamous
epithelial cells. Alveolar pores connect neighboring air sacs an% provi%e alternate routes !or air
to reach alveoli whose !ee%er bronchioles have been clogge% by mucus or otherwise covere%
with a 8cobweb9 o! pulmonary capillaries. The alveolar an% capillary walls construct the
respiratory membrane +air/bloo% barrier, which has gas +air, !lowing past on one si%e an% bloo%
!lowing past on the other. The gas e'changes occur by simple %i!!usion through the respiratory
membrane : o'ygen passing !rom the alveolar air into the capillary bloo% an% carbon %io'i%e
leaving the bloo% to enter the gas/!ille% alveoli. The !inal line o! %e!ense !or the respiratory
system is in the alveoli. The cuboi%al cells pro%uce a lipi% molecule calle% sur!actant which
coats the gas/e'pose% alveolar sur!aces an% is very important in lung !unction.
Respiratory Physiology
The ma)or !unction o! the respiratory system is to supply the bo%y with o'ygen an% to %ispose
carbon %io'i%e. There are !our events that must occur;
1. Pulmonary ventilation +breathing, : Air moves in an% out o! the lungs wherein gases in
the alveoli are continuously change% an% re!reshe%.
". E'ternal respiration : <as e'change between the bloo% an% the bo%y e'terior.
2. Respiratory gas transport : O'ygen an% carbon %io'i%e are transporte% to an% !rom the
lungs an% tissue cells o! the bo%y via the bloo%stream.
=. Internal respiration : <as e'changes are occurring between the bloo% an% cells insi%e
the bo%y.
Mechanics o! 6reathing
6reathing +pulmonary ventilation, is a completely mechanical process that %epen%s on
volume changes occurring in the thoracic cavity. It involves two phases inspiration +inhalation,
where air is !lowing into the lungs through the contraction o! the %iaphragm an% e'ternal
intercostals which there!ore increases the si7e o! the thoracic cavity an% e'piration +e'halation,
where air leaves the lungs causing the inspiratory muscles to rela' an% resume their initial
resting length that %escen%s the rib cage an% recoils the lungs.
PATHOPHYSIOLOGY
SYMPTOMATO4O<Y
SYMPTOMS A&T>A4 O&&>RE-&E ?>STI(I&ATIO-
(ever 6o%y %e!ense mechanism is
to increase thermoregulation
by the hypothalamus
releasing pyrogens which
increases bo%y core
temperature to remove
bacteria or inva%ing pathogen.
&ough I &ause% by in!lammation an%
irritation o! the passages in
the lungs which is sense% by
small nerve en%ings which
trigger the cough
Tachypnea I &ause% by increase in
in!lammatory me%iators seen
in in!ection an% catecholamine
levels associate% with the
stress response. There may
also be lower levels o!
o'ygenation an% increase%
wor$ o! breathing. I! there is
some %egree o! respiratory
muscle !atigue then this
stimulates rapi% shallow
breathing as well.
.yspnea I Results !rom a %isassociation
or a mismatch between
central respiratory motor
activity an% incoming a!!erent
in!ormation !rom receptors in
the airways lungs an% chest
wall structures
-ausea an% vomiting Results !rom in!ection an%
high gra%e !ever
.iarrhea Occurs when there is %amage
to the mucosal lining or brush
bor%er which lea%s to a
passive loss o! protein/rich
!lui%s an% a %ecrease% ability
to absorb these lost !lui%s
?aun%ice Results !rom %amage o! the
bloo% e'cessively %estroye%
bloo% cells whose pigment
may be %eposite% in the
tissues.
>se o! accessory muscles I Inspiratory accessory muscles
might be use% with certain
con%itions such as
pneumonia an allergic
reaction causing anaphyla'is
an asthma attac$ or an
obstruction that %oes not allow
a%e#uate air
-asal !laring I Enlargement o! the opening o!
the nostrils %uring breathing. It
is o!ten a sign that increase%
e!!ort is nee%e% to breathe.
&yanosis .ue to lac$ o! o'ygen in the
bloo%stream
Poor !ee%ing Result o! %ecrease in the brain
impulses that stimulates the
!unction o! the taste bu%s
because o! the vascular
changes in the cephalic area.
Since the alveoli where !ille%
with !lui%s an% e'u%ates gas
e'change was not
accomplishe% well
ETIO4O<I& (A&TORS
PRE.ISPOSI-< (A&TOR A&T>A4 O&&>RE-&E ?>STI(I&ATIO-
Age I Pneumonia $ills an estimate%
1." million chil%ren un%er the
age o! !ive years every year
Se' Occurrence o! the sai%
%isease in prevalent in males
more it is in !emales.
Testosterone may suppress
the immune system by
changing the way men@s
bo%ies allocate important
resources such as ta$ing
energy away !rom the immune
system an% using it !or other
purposes.
In%oor Air Pollution In%oor air pollution !rom
biomass !uels has been
%etermine% to elevate the ris$
o! pneumonia in chil%ren by
appro'imately A5B.
Assessment o! in%oor
concentrations o! particulate
matter or carbon mono'i%e to
in%irect reports o! !uel an%
stove use an% househol%
cigarette smo$ing are %one
Malnutrition This is crucial in the
strengthening o! the immune
system o! the client. Cithout
the su!!icient inta$e o!
vitamins an% minerals that are
present in the %iet the
%e!ense mechanism o! the
bo%y is wea$ene%0 ma$ing it
susceptible to in!ection an%
invasion o! possible
microorganisms that are
present in the environment.
This can be attribute% to the
possibility that these
microorganisms are %welling
in the environment itsel!.
&row%ing 4iving in crow%e% con%itions
promotes the transmission o!
airborne pathogens. Thus
crow%ing commonly
measure% as the number o!
persons per room in a
%welling unit
P-E>MO-IA
The term pneumonia %escribes in!lammation o! parenchymal structures o! the lung such
as the alveoli an% the bronchioles. Although antibiotics have signi!icantly re%uce% the mortality
rate !rom pneumonias these %iseases remain the si'th lea%ing cause o! %eath in the >nite%
States an% an important imme%iate cause o! %eath in the el%erly an% persons with %ebilitating
%iseases. Etiologic agents inclu%e in!ectious an% nonin!ectious agents.
&lassi!ication
Pneumonias can be classi!ie% accor%ing to the type o! agent +typical or atypical, causing
the in!ection %istribution o! the in!ection +lobar pneumonia or bronchopneumonia, an% setting
+community or hospital, in which it occurs.
Typical pneumonias result !rom in!ection by bacteria that multiply e'tracellularly in the
alveoli an% cause in!lammation an% e'u%ation o! !lui% into the air/!ille% spaces o! the alveoli.
Atypical pneumonias are cause% by viral an% mycoplasma in!ections that involve the alveolar
septum an% interstitium o!t the lung. They pro%uce less stri$ing symptoms an% physical !in%ings
than bacterial pneumonia0 there is a lac$ o! alveolar in!iltration an% purulent sputum
leu$ocytosis an% lobar consoli%ation in the ra%iograph. Acute bacterial pneumonias can be
classi!ie% as lobar pneumonia or bronchopneumonia base% on their anatomic pattern o!
%istribution. In general lobar pneumonia re!ers to consoli%ation o! a part or all o! a lung lobe
an% bronchopneumonia signi!ies a patchy consoli%ation involving more than one lobe.
6ecause o! the overlap in the symptomatology an% changing spectrums o! in!ectious
microorganisms involve% pneumonias are increasingly being classi!ie% accor%ing to the setting
+community/ac#uire% or hospital/ac#uire%, in which they occur.
&OMM>-ITY/A&D>IRE. P-E>MO-IA
It is use% to %escribe in!ections !rom organisms !oun% in the community rather than in
the hospital or nursing home. It is %e!ine% as an in!ection that begins outsi%e the hospital or is
%iagnose% within =A hours a!ter a%mission to the hospital in a person who has not resi%e% in a
long/term care !acility !or 1= %ays or more be!ore a%mission. &ommunity/ac#uire% pneumonias
may be !urther categori7e% accor%ing to ris$ o! morality an% nee% !or hospitali7ation base% on
age presence o! coe'isting %isease an% severity o! illness as %etermine% by physical
e'amination laboratory an% ra%iologic !in%ings.
&ommunity/ac#uire% pneumonias may either be bacterial or viral. The most common
cause is S. pneumoniae. Other common pathogens inclu%e H. influenza, S. aureus gram/
negative bacilli. 4ess common agents are M. catarrbalis. &ommon viral causes inclu%e the
in!luen7a virus respiratory syncytial virus a%enovirus an% parain!luen7a virus.
The metho%s use% in %iagnosing %epen% on age coe'isting health problems an% the
severity o! illness. In persons younger than EF years o! age an% without coe'isting %isease the
%iagnosis is usually base% on history an% physical e'amination chest ra%iographs an%
$nowle%ge o! the microorganisms currently causing in!ections in the community. Sputum
specimens may be obtaine% !or staining proce%ures an% culture. 6loo% culture may be %one !or
person re#uiring hospitali7ation.
*OSPITA4/A&D>IRE. P-E>MO-IA
Also terme% as nosocomial is %e!ine% as lower respiratory tract in!ection that was not
present or incubating on a%mission to the hospital. >sually in!ections occurring =A hours or
more a!ter a%mission are consi%ere% hospital/ac#uire%.
G5B o! in!ections are bacterial. The organisms are those present in the hospital
environment an% inclu%e Pseudomonas aeruginosa, S. aureus, Enterobacteria species
Klebsiella species Escherichia coli, an% Serratia. Many o! these have ac#uire% antibiotic
resistance an% are more %i!!icult to treat.
&O-TRI6>TI-<
(A&TOR;
PRE.ISPOSI-<
(A&TOR;
Age
Staphylococcus
pneumoniae
Organisms enter the respiratory
tract through
inspirationHaspiration
Activation o! %e!ense mechanism
4ose e!!ectiveness o! %e!ense
mechanism
Penetrate the sterile lower
respiratory tract +lungs,
Alveol
i
multiplies Irritation o! airway
Increase goblet
cells
&oloni7atio
n
Release %amaging
to'ins
A
6 &
In!ection Occlu%e% the
airway
Increase
mucus
pro%uction
In!lammatio
n
Iaso%ilation
E'u%ates
come !rom
bacteria ero%e
the lung
&oug
h
&rac$le
s
P-E>MO-IA
Iiral In!ection
In!luen7a
(ungal In!ection
Pseu%omonas
&an%i%a
6acterial In!ection
Staphylococcus
Streptococcus
Pneumococcus
Increase
bloo% !low
.ea%
space
happene%
*yperventilation Airway
constrictio
n
Plasma an%
&*O- rich !lui%
lea$age
Accumulation o!
e%ematous !lui%
In!lame% an% !lui%/
!ille% alveolar sacs
Increase%
respiratory
.i!!iculty in
breathing
.ecrease%
&O"
4ung
consoli%ation
*ypo'i
a
Impaire% &O"
an% O"
e'change
Ientilation
%eman%s
A%enovirus
Respiratory syncytial virus
In!lammation o! pulmonary parenchyma
6ronchopneumonia
Interstitial
Pneumonia
4obar Pneumonia
Mucopurulent e'u%ate in
terminal bronchioles
&logging o! bronchioles
-ecrosis an% sloughing o!
bronchial mucous
membranes
(ormation o! peribronchial
abscesses an%
pneumatoceles
>sually Staphylococcal
In!lammation o! walls o!
alveoli bronchi an%
bronchioles
>sually viral or
treptococcal
Resolution
with
treatment
Pleural
e!!usion
Empyema
Engorgement with e!!usion o!
bloo% an% serum into alveoli in
one or more lobes +Stage I,
4obe airless an% alveoli contain
!ibrin serum R6&s neutrophils
+Stage II,
4ove larger with !ibrin in alveoli
an% %ecrease% cellular
elements an% bacteria +Stage
III,
>sually Pneumococca
Resolution
with treatment
Pneumothrora'
Empyema
Resolution
with
treatment
Pleural
e!!usion
Pleurisy
Empyema