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NY 10010.2—dc22 2010014243 Manufactured in the United States of America On the cover: The human lungs are extraordinary organs that constantly pump crucial oxygen through airways and into the bloodstream. 226. cm. Inc. p. Copyright © 2011 Encyclopædia Britannica. Britannica. Rogers. Levy: Executive Editor J. All rights reserved. Editorial Technologies Lisa S. 196.R467 2011 612. 122.) in association with Rosen Educational Services. -. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. 60. Chip Somodevilla/Getty Images On pages 19. Respiratory organs—Popular works. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. Rosen Educational Services. Distributed exclusively by Rosen Educational Services. 87. © www. Media Acquisition Kara Rogers: Senior Editor. Rosen Educational Services materials copyright © 2011 Rosen Educational Services.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. All rights reserved. For a listing of additional Britannica Educational Publishing titles.istockphoto.E. QP121. © www. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. 159. call toll free (800) 237-9932. Production Control Steven Bosco: Director. Inc.istockphoto. I. Encyclopædia Britannica. LLC 29 East 21st Street. ISBN 978-1-61530-147-8 (library binding) 1. LLC. 41. Barton: Senior Coordinator. First Edition Britannica Educational Publishing Michael I. Biomedical Sciences Rosen Educational Services Heather M.com / nicoolay .(The human body) “In association with Britannica Educational Publishing. 230: A healthy set of lungs is the powerhouse behind the respiratory system. Kara. 228.” Includes bibliographical references and index. Luebering: Senior Manager Marilyn L.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. Inc. New York. and the Thistle logo are registered trademarks of Encyclopædia Britannica.
and Nerves 36 Lung Development 38 Chapter 2: Control and Mechanics of Breathing 41 Control of Breathing 41 Central Organization of Respiratory Neurons 44 Chemoreceptors 46 Peripheral Chemoreceptors 46 Central Chemoreceptors 48 Muscle and Lung Receptors 49 Variations in Breathing 50 Exercise 51 Sleep 52 32 43 51 .CONTENTS Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels. Lymphatic Vessels.
61 The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration. Circulation. and Metabolism 73 Adaptations 78 High Altitudes 79 Swimming and Diving 81 Chapter 4: Infectious Diseases of the Respiratory System 87 Upper Respiratory System Infections 88 Common Cold 88 Sore Throat 91 Pharyngitis 91 Sinusitis 92 Tonsillitis 94 Lower Respiratory System Infections 95 Laryngitis 95 Tracheitis 96 Croup 98 Infectious Bronchitis 99 Bronchiolitis 100 Influenza 102 Whooping Cough 105 77 .
Psittacosis 107 Pneumonia 108 Legionnaire Disease 113 Tuberculosis 114 Chapter 5: Diseases and Disorders of the Respiratory System 122 Disorders of the Upper Airway 122 Snoring 123 Sleep Apnea 124 Pickwickian Syndrome 126 Diseases of the Pleura 126 Pleurisy 127 Pleural Effusion and Thoracic Empyema 127 Pneumothorax 129 Diseases of the Bronchi and Lungs 130 Bronchiectasis 130 Chronic Bronchitis 131 Pulmonary Emphysema 133 Chronic Obstructive Pulmonary Disease 136 Lung Congestion 138 Atelectasis 141 Lung Infarction 144 Cystic Fibrosis 145 Idiopathic Pulmonary Fibrosis 149 Sarcoidosis and Eosinophilic Granuloma 149 Pulmonary Alveolar Proteinosis 150 Immunologic Conditions of the Lung 151 Lung Cancer 152 Diseases of the Mediastinum and Diaphragm 156 115 123 .
165 167 181 Chapter 6: Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 159 Allergic Lung Diseases 159 Asthma 160 Hay Fever 164 Hypersensitivity Pneumonitis 166 Occupational Lung Disease 167 Silicosis 169 Black Lung 170 Asbestosis and Mesothelioma 171 Respiratory Toxicity of Glass and Metal Fibres 173 Byssinosis 174 Respiratory Toxicity of Industrial Chemicals 175 Disability and Attribution of Occupational Lung Diseases 176 Other Respiratory Conditions 177 Circulatory Disorders 177 Respiratory Distress Syndrome 179 Air Pollution 180 Carbon Monoxide Poisoning 183 Acidosis 184 Alkalosis and Hyperventilation 184 Hypoxia 186 Altitude Sickness 188 Barotrauma and Decompression Sickness 189 Thoracic Squeeze 192 Drowning 193 Chapter 7: Approaches to Respiratory Evaluation and Treatment 196 Recognizing the Signs and Symptoms of Disease 196 .
Methods of Investigation 199 Pulmonary Function Test 202 Chest X-ray 203 Lung Ventilation/Perfusion Scan 204 Bronchoscopy 205 Mediastinoscopy 208 Types of Respiratory Therapy 210 Drug Therapies 211 Oxygen Therapy 214 Artificial Respiration 218 Thoracentesis 220 Hyperbaric Chamber 221 Lung Transplantation 223 Conclusion 223 202 Glossary 226 Bibliography 228 Index 230 219 .
eventually reaching the region where gas is exchanged. Air that passes through the nose travels to the pharynx. After passing through the larynx.7 Introduction 7 he human lungs are amazing feats of nature. Inside the lungs. or voice box. A thin membranous sac known as the pleura covers the lungs. The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. This structure provides humans with the sense of smell while also filtering. The right lung has 10 airway segments. humans could not survive on Earth. It also sheds light on how easily a healthy respiratory system can be damaged. the most prominent feature of the lung interior are the many small air passages called 11 T . This book explains the science behind the amazing human respiratory system. or throat. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. The clean air then travels into the deep tissues of the lungs. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. air travels through the trachea. They pump vital oxygen through airways and into the bloodstream every second of every day. there are numerous nerves and blood vessels. the cone-shaped passageway leading from the mouth and nose to the larynx. and the left lung has 8 to 10. and moistening inhaled air. the centre of the respiratory system. the air is cleansed and moistened before entering the lungs. warming. The larynx is a hollow tube connected to the top of the windpipe. Here. also known as the windpipe. whether by a viral or bacterial infection or through detrimental habits such as smoking. But there are many treatments to keep the airways free and clear. Without this ability. However.
humans and other animals do not need to actively think about breathing in order for it to happen. The tissue compartment supports the air and blood compartments and lets them come into close contact. The act of breathing. The gas-exchange area.12 inch) to less than 1 mm (less than 0. the pulmonary system. which range in diameter from 3 mm (0. The bronchial circulation is a vital source of nourishment for the lung tissues. The average adult lung has approximately 300 million alveoli.04 inch). The first of these. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. which makes exchanging gases easier. the bronchial circulation. comprises the network of blood vessels supporting the conducting airways themselves. The second blood system in the lungs. or respiration. through the pulmonary arteries. Thus. From the heart.7 The Respiratory System 7 bronchioles. and tissue. the region where oxygen is transferred to the blood and carbon dioxide is removed. the oxygenated blood is pumped to the rest of the body. but still keeps them separate. is an automatic process. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs. Lungs also have two distinct blood circulation systems. which look like cells in a honeycomb. thereby delivering oxygen and other nutrients to organs distant from the lungs. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. controlled by the brain. air. is made up of three separate compartments for blood. and to the left atrium of the heart. through the pulmonary veins. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 .
Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. these receptors constrict the airways and cause breathing to become fast and shallow. One of the major abdominal muscles involved in breathing is the diaphragm. In the basic mechanics of breathing. thereby increasing oxygen delivery to tissues and maintaining the body’s acid–base balance. metabolic rate slows and therefore respiration rate decreases and oxygen demand is low. respectively. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. The 13 . which functions to move air in and out of the lungs as it contracts and relaxes. air moves in and out of the lungs in response to pressure changes. One of the most notable features of respiratory control is the way in which neural communication between the body and the brain fine-tunes the rate of breathing in order to keep carbon dioxide pressure in the blood constant. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. which are located throughout the body. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. This response represents the body’s attempt to prevent toxins from entering the lungs. During exercise. metabolic rate and acid levels in muscle tissue increase. during sleep. others respond to chemical changes in the immediate external environment. In addition to the types of sensors described above. there also exist sensors that monitor the muscles that control breathing. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep.7 Introduction 7 abdomen. When stimulated. These effects trigger an increase in respiration rate. In contrast.
The amount of air that the lungs pump changes dramatically depending on external or internal conditions. circulation. during vigorous breathing. acclimatization. At high altitudes. and metabolism all work together. but it is assisted by a complex assembly of other muscle groups. In adults. However. hiking up during the day and descending down to camp to 14 . The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. The oxygen that the alveoli transfer to the blood is then circulated to the heart and the body’s other tissues. transfer carbon dioxide from and add oxygen to blood. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. People who live at high altitudes adapt to this decrease in oxygen availability. Without oxygen. The pulmonary alveoli. Oxygen is used by cells for the breakdown of nutrients. oxygen is present at lower levels than it is at low altitudes. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. an activity that is necessary to supply energy to the cells and the body.7 The Respiratory System 7 diaphragm is the major muscle that facilitates breathing. Respiration. which can lead to death. the small air spaces in the lungs. in which the body works to more efficiently utilize oxygen in the air. This exchange of gases takes place over an immense surface area. even for only a few minutes. is a gradual process. can cause the brain and the heart to stop functioning. Oxygen deprivation. cells are unable to function properly. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. The main purpose of respiration is to provide oxygen for the body’s cells.
certain viruses and fungi can also cause the disease. In the lower respiratory system. Pneumonia also often affects persons with impaired immune systems. Tuberculosis is another example of a respiratory disease caused by bacteria. Other common upper respiratory conditions include sore throat and pharyngitis. as well as bacterial pneumonia. the body’s tissues become deprived of oxygen. Before antibiotics were widely available. The 15 . This enables the body to adjust to the decreased availability of oxygen. In the 18th and 19th centuries. which can arise as a result of infection. For example. many people have their tonsils removed after suffering from chronic tonsillitis. Although bacteria sometimes cause pneumonia. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. as climbers make their way up the mountain. which can be particularly dangerous in infants and in the elderly. death is caused by drowning. and in the first decade of the 21st century. If these precautions are not taken. in which the body circulates additional blood to the lungs. but the blood leaks into the air sacs. which can lead to high-altitude pulmonary edema. Essentially. bacteria can cause inflammation of the trachea. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. a condition known as tracheitis. pneumonia was a widespread and notoriously deadly disease. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. Inflammation of respiratory tissues can sometimes be severe and chronic. because these individuals are unable to defend against infectious organisms.7 Introduction 7 sleep at night. it was a leading cause of death.
It is a highly contagious disease too. One of the best-characterized inherited conditions is cystic fibrosis. resulting in the formation of cavities in the lungs. seasonal respiratory illness that is caused by viral infection. For some diseases of the respiratory system. Many respiratory conditions arise from noninfectious causes. One example is idiopathic pulmonary fibrosis. a strain of influenza virus gives rise to a pandemic. Every few decades. which caused between 25 million and 50 million deaths worldwide. One of the deadliest influenza pandemics was that of 1918–19. Eventually. or large cheese-like masses. This process leads to the eventual breakdown of respiratory tissues. and the infected person coughs up bright red blood. snoring is caused by blocked airways. A respiratory disease of major concern in the world today is lung cancer. in which the collapse of the airways leads to intermittent stoppages in breathing. and stomach pain. despite extensive research. chills. The term idiopathic means “of unknown cause. Sleep apnea causes affected individuals to awaken periodically through the night. blood vessels in the lungs burst. the primary symptom of which is the production of a thick. Some respiratory diseases are inherited. which may be associated with obesity.” and thus is used to describe diseases of uncertain origin. muscle pains. headaches. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. Lung cancer can arise as a result of a 16 . no cause has been identified. sticky mucus that blocks the airways and the digestive tract. For example. A severe form of snoring is sleep apnea. Influenza is a common.7 The Respiratory System 7 tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). which results in progressive shortness of breath until a person can no longer breathe. Infection is accompanied by fever. to form.
most likely resulting from exposure to air pollution. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. or work. Doctors first described the symptoms of lung cancer in the mid-19th century. In the early 20th century. tobacco smoke. particularly pneumonia and tuberculosis. Now. lung cancer is the leading cause of cancer deaths worldwide. however. however. have been around for years and are readily available. There is hope for those who suffer from respiratory diseases and disorders. more than 7 percent of children and 9 percent of adults suffer from asthma. In addition to vaccines and antivirals. Several vaccines have been developed to prevent illnesses such as influenza.7 Introduction 7 variety of factors. although tobacco smoking is the primary cause. The best-known occupational lung disease is black lung. resulting in an estimated 1. and even cockroaches. Some respiratory diseases arise as a result of occupational. Many treatments. Today. Construction workers and insulators exposed to asbestos often suffer from asbestosis. which affects coal miners who inhale coal dust for many years. Breathing asbestos can also cause the cancerous condition known as mesothelioma. The antiviral agents Tamiflu (oseltamivir) and Relenza (zanamivir) played an important role in treating persons affected by influenza during the H1N1 influenza pandemic of 2009. Scientists are constantly researching and developing new and different treatments for respiratory ailments. 17 . it was still considered rare. Nasal decongestants and antihistamines are examples of commonly used remedies. or white lung disease. Breathing problems caused by allergies to environmental conditions are fairly common.3 million fatalities each year. factors.
As this book shows. A healthy set of lungs is nothing to take for granted. Treatment may also be based on the results of genetic screening. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant.7 The Respiratory System 7 Lung cancer treatments may consist of surgery. chemotherapy. . which can identify mutations that render some lung cancers susceptible to certain drugs. and the consequences of neglecting or damaging that fragile system can be drastic. and radiation. the human respiratory system is a finely tuned feat of engineering. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place.
CHAPTER1 ANATOMY AND FUNCTION OF THE HUMAN RESPIRATORY SYSTEM O ur respiratory system provides us with the fundamental ability to breathe: to inhale and exhale air from our lungs. The lower airway system consists of the larynx. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. supporting this process are a number of complex actions that occur within our bodies. and all the airways that branch extensively within the lungs. is fundamental to survival. These actions encompass not only muscular movements but also cellular and chemical processes. the bronchioles. such as the intrapulmonary bronchi. the lung. Breathing. the pharynx (or throat). and the alveolar ducts. as simple as it is for us to inhale and exhale. occurring without our having to think about it. the stem bronchi. The upper airway system comprises the nose and the paranasal cavities (or sinuses). just at the top of the larynx (or voice box). and part of the oral cavity. it is otherwise an automatic process. and though we possess the ability to consciously control the rate of our breathing. is located in the thorax (or chest). Yet. the design of the respiratory systeM The human gas–exchanging organ. the trachea. or respiration. The respiratory system consists of two divisions: upper airways and lower airways. where its delicate tissues are 19 .
Inc.7 The Respiratory System 7 The lungs serve as the gas-exchanging organ for the process of respiration. carbon dioxide. 20 . called conducting airways. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product. protected by the bony and muscular thoracic cage. Atmospheric air is pumped in and out regularly through a system of pipes. Encyclopædia Britannica.
The Nose The nose is the external protuberance of an internal space. and it protects against the passage into the lungs of potentially infectious foreign agents. the nasal 21 . is sometimes also considered a part of the upper airways. The diaphragm. In addition to fulfilling a fundamental role in respiration. whose bony framework is formed by the ribs and the thoracic vertebrae. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract. the pumping action on the lung.. the heart and the blood vessels). sinuses. and the circulatory system (i.7 Anatomy and Function of the Human Respiratory System 7 which connect the gas–exchange region inside the body with the environment outside the body. The muscles expand and contract the internal space of the thorax. through which air may be inhaled or exhaled. The oral cavity. the nasal cavity. the collaboration of other organ systems is essential. The filtering process is vital to clearing inhaled air of dust and other debris. Other elements fundamental to the process of respiration include the blood. as the main respiratory muscle. the structures of the upper respiratory tract also have other important functions. such as enabling the sensation of smell. under the control of the central nervous system. and the intercostal muscles of the chest wall play an essential role by generating. For respiration. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. which acts as a carrier of gases. which pumps blood from the heart to the lungs and the rest of the body.e. Morphology of the upper airways The nose.
consists principally of two cell types. from the lateral wall. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa.7 The Respiratory System 7 septum. and they serve as resonance chambers for the human voice. via the nasolacrimal duct. The sinuses have two principal functions: because they are filled with air. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also. the epithelium. On each side. they are called the maxillary sinus. middle. and the sphenoid sinus. which is the largest cavity. This structural design 22 . and sphenoid bones. Correspondingly. the frontal sinus. which is located in the upper posterior wall of the nasal cavity. Each canal opens to the face by a nostril and into the pharynx by the choana. which also forms the roof of the oral cavity. middle. the ethmoid sinuses. with the lacrimal apparatus in the corner of the eye. and inferior turbinate bones (or conchae). frontal. Typically. ciliated and secreting cells. the mucosa of the nose contains mucus-secreting glands and venous plexuses. and inferior nasal meatuses. The paranasal sinuses are sets of paired single or multiple cavities of variable size. The floor of the nasal cavity is formed by the palate. ethmoid. they help keep the weight of the skull within reasonable limits. Most of their development takes place after birth. Its top cell layer. The duct drains the lacrimal fluid into the nasal cavity. it is also flooding the nasal cavity. The complex shape of the nasal cavity results from projections of bony ridges. The passageways thus formed below each ridge are called the superior. and they reach their final size around age 20. The sinuses are located in four different skull bones: the maxilla. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. the superior.
is lined by skin that bears short thick hairs called vibrissae. the olfactory organ with its sensory epithelium checks the quality of the inspired air. The vestibule. Encyclopædia Britannica. Inc. and warm the inspired air. Two regions of the nasal cavity have a different lining. In the roof of the nose. moisten. reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. About two dozen olfactory nerves convey the sensation of smell from the 23 . a process that saves water and energy.7 Anatomy and Function of the Human Respiratory System 7 Sagittal view of the human nasal cavity. the air is dried and cooled. During expiration through the nose. at the entrance of the nose. They clean. preparing it for intimate contact with the delicate tissues of the gas-exchange area.
the pharynx can be divided into three floors. Inc. the nasopharynx. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls.7 The Respiratory System 7 olfactory cells through the bony roof of the nasal cavity to the central nervous system. The act of swallowing briefly opens the normally collapsed auditory tubes and allows the middle ears to be aerated and pressure differences to be equalized. The Pharynx For the anatomical description. The upper floor. In the posterior wall of the Sagittal section of the pharynx. 24 . Encyclopædia Britannica. is primarily a passageway for air and secretions from the nose to the oral pharynx.
It is delimited from the nasopharynx by the soft palate. leafshaped flap. which is the second–largest hollow space of the body. When it is enlarged (as in tonsil hypertrophy). The cavity is enclosed by the ribs. and food from the oral cavity is routed to the esophagus directly behind the larynx. Also residing within the thoracic cavity is the tracheobronchial tree: the heart.7 Anatomy and Function of the Human Respiratory System 7 nasopharynx is located a lymphatic organ. 25 . and lungs. it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx. The first two of these provide a canal for the passage of air to the lungs. the vessels transporting blood between the heart and the lungs. during the act of swallowing. the vertebral column. the pharyngeal tonsil. The lungs reside within the thoracic cavity (chest cavity). trachea. The lower floor of the pharynx is called the hypopharynx. Lying directly above the larynx. controls the traffic of air and food. Morphology of the lower airways The major structures of the lower airways include the larynx. the diaphragm. a cartilaginous. the great arteries bringing blood from the heart out into general circulation. The middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx. which roofs the posterior part of the oral cavity. functions as a lid to the larynx and. The epiglottis. while the lungs themselves receive the air and facilitate the process of gas exchange. Its anterior wall is formed by the posterior part of the tongue. and the sternum (or breastbone) and is separated from the abdominal cavity (the body’s largest hollow space) by a muscular and membranous partition. it may interfere with nasal respiration and alter the resonance pattern of the voice.
most of them minute. when it occurs. The Larynx The larynx is an organ of complex structure that serves a dual function: as an air canal to the lungs and a controller of its access. and over part of the esophagus.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. the thyroid cartilage. and the great vessels. or serum. The laryngeal skeleton consists of almost a dozen pieces of cartilage. the mediastinum being the space and the tissues and structures between the two lungs. As evidenced by trained singers. is made of two plates fused 26 . as the mediastinal pleura. The largest cartilage of the larynx. The pleural cavity is the space. the heart. between the parietal and the visceral pleura. this function can be closely controlled and finely tuned. The chest cavity is lined with a serous membrane. Sound is produced by forcing air through a sagittal slit formed by the vocal cords. This causes not only the vocal cords but also the column of air above them to vibrate. Control is achieved by a number of muscles innervated by the laryngeal nerves. the glottis. The membrane continues over the lung. interconnected by ligaments and membranes. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. and as the organ of phonation. the two surfaces tend to touch. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. the muscles must be anchored to a stabilizing framework. This portion of the chest membrane is called the parietal pleura. where it is called the visceral pleura. For the precise function of the muscular apparatus. so called because it exudes a thin fluid.
made of elastic tissue. Behind the shieldlike thyroid cartilage. below it is a forward projection. with its narrowest width at the glottis. They correspond to elastic ligaments attached anteriorly in the angle of the thyroid shield and posteriorly to a pair of small pyramidal pieces of cartilage. the vocal cords span the laryngeal lumen. Both of these structures are easily felt through the skin. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. they follow its tilting movement. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. Like the true vocal cords. Because the arytenoid cartilages rest upright on the cricoid plate. another large cartilaginous piece of the laryngeal skeleton. the epiglottis is also attached to the back of the thyroid plate by its stalk. the thyroid notch. resembling an organ pipe. The vocal ligaments are part of a tube. which has given this structure the common name of Adam’s apple.7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. has a signet-ring shape. the lumen of the laryngeal tube has an hourglass shape. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. The cricoid is located below the thyroid cartilage. the arytenoid cartilages. to which it is joined in an articulation reinforced by ligaments. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. the laryngeal prominence. Viewed frontally. they are also formed by the free end 27 . Just above the vocal cords. The cricoid. The transverse axis of the joint allows a hingelike rotation between the two cartilages. At the upper end of the fusion line is an incision. This mechanism plays an important role in altering length and tension of the vocal cords.
g. the trachea divides in an inverted Y into the two stem (or main) bronchi. and is shorter than the left main bronchus. Because the gap between the vestibular folds is always larger than the gap between the vocal cords. and tension of the vocal cords. length. The muscular apparatus of the larynx comprises two functionally distinct groups.7 The Respiratory System 7 of a fibroelastic membrane. one each for the left and right lung. The interior of the trachea is lined by the typical respiratory epithelium. during high-pitched phonation or swallowing) or downward. The Trachea and the Stem Bronchi Below the larynx lies the trachea.. Between the vestibular folds and the vocal cords. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped.8 inch) wide. The mucosal layer contains mucous glands. At its lower end. moving it upward (e. The practical consequence of 28 . incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. an instrument designed for visual inspection of the interior of the larynx. The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. the laryngeal space enlarges and forms lateral pockets extending upward. The intrinsic muscles act directly or indirectly on the shape. The extrinsic muscles act on the larynx as a whole. the latter can easily be seen from above with the laryngoscope. The intrinsic muscles attach to the skeletal components of the larynx itself. The right main bronchus has a larger diameter. is oriented more vertically. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. This space is called the ventricle of the larynx.
where both functions grade into one another. if the trachea is counted as generation zero. and partly also of the blood vessels penetrating the lung. purely conducting zone. however. may range from 11 to 30 generations. it makes sense to distinguish the relatively thick-walled. In modeling the human airway tree. however. however. The structure of the stem bronchi closely matches that of the trachea. largely determines the internal lung structure. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. structural design of the airway tree The hierarchy of the dividing airways. purely gas-exchanging zone. the intrapulmonary airway system can be subdivided into three zones: a proximal. the daughter branches may differ greatly in length and diameter. 29 . and a transitional zone in between. From a morphological point of view. In irregular dichotomy. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions.7 Anatomy and Function of the Human Respiratory System 7 this arrangement is that foreign bodies passing beyond the larynx will usually slip into the right lung. it is generally agreed that the airways branch according to the rules of irregular dichotomy. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. Functionally. Individual paths. a peripheral.
the bronchi. In larger airways. devoid of cartilage. their height decreasing with the narrowing of the tubes. Distally. this fluid layer is topped by a blanket of mucus of high viscosity. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. moisten. The last purely conductive airway generations in the lung are the terminal bronchioles. within which the cilia exert a synchronized. gain their stability from their structural integration into the gas-exchanging tissues. the alveoli are so densely packed along the airway that an airway wall 30 . rhythmic beat directed outward.7 The Respiratory System 7 The conducting airways comprise the trachea. the two stem bronchi. the walls of the bronchioles. and the bronchioles. and indeed the mechanism is referred to as the mucociliary escalator. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. where they are swallowed. After several generations of such respiratory bronchioles. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. Ciliated cells are present far down in the airway tree. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. This design can be compared to a conveyor belt for particles. The epithelium is covered by a layer of low-viscosity fluid. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. Their function is to further warm. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. In the alveoli. as does the frequency of goblet cells.
blood and lymphatic vessels. the lungs Humans have two lung organs. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. Medially. and the airway consists of alveolar ducts. the lungs occupy most of the intrathoracic space. In humans each lung is encased in a thin membranous sac called the pleura. they are connected with the mediastinum at the hilum. The space between them is filled by the mediastinum. a circumscribed area where airways. has only two lobes separated by an oblique fissure. and the thymus gland. a right and a left. while their apexes extend above the first rib. the trachea with the stem bronchi. which corresponds to a connective tissue space containing the heart. middle. and nerves enter or leave the lungs. The final generations of the airway tree end blindly in the alveolar sacs. the two lungs rest with their bases on the diaphragm. the esophagus. The right and left lungs are slightly unequal in size. The right lung represents 56 percent of the total lung volume and is composed of three lobes. Gross Anatomy Together. major blood vessels.7 Anatomy and Function of the Human Respiratory System 7 proper is missing. In the thorax. a superior. smaller in volume because of the asymmetrical position of the heart. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. separated from each other by a deep horizontal and an oblique fissure. and inferior lobe. The parietal pleura and the visceral pleura that line the inside 31 . The left lung.
The presence of pleural recesses form a kind of reserve space. the parietal pleura can be subdivided into three portions: mediastinal. are in direct continuity at the hilum. Although the hilum is the only place where the lungs are secured to surrounding structures. respectively. the recesses are partly opened by the expanding lung. thus allowing the lung to increase in volume.7 The Respiratory System 7 Anatomy of the human lungs. and diaphragmatic pleurae. Inc. of the thoracic cavities and the lung surface. A thin film of extracellular fluid between the pleurae enables 32 . the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. Depending on the subjacent structures. During inspiration. Encyclopædia Britannica. costal. so the pleural cavity is larger than the lung volume.
Bronchioles are 33 . the pulmonary segments. and breathing is abolished on this side. depending on the classification. There are 10 segments in the right lung and 8 to 10 segments in the left lung. besides lymphatics and nerves. and the surgeon can remove single diseased segments instead of whole lobes. Unlike the lobes. The bronchi are ensheathed by a layer of loose connective tissue that is continuous with the other connective tissue elements of the lung and hence is part of the fibrous skeleton spanning the lung from the hilum to the pleural sac. This outer fibrous layer contains. If air enters a pleural cavity (pneumothorax). small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. These anatomical features are important because pathological processes may be limited to discrete units. Furthermore.7 Anatomy and Function of the Human Respiratory System 7 the lungs to move smoothly along the walls of the cavity during breathing. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. respiratory movements can be painful. the arterial supply follows the segmental bronchi. the lung immediately collapses owing to its inherent elastic properties. the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. Pulmonary Segments The lung lobes are subdivided into smaller units. If the serous membranes become inflamed (pleurisy). The Bronchi and Bronchioles In the intrapulmonary bronchi.
until after two to four generations of respiratory bronchioles. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells. blood. The gas-exchange tissue proper is called the pulmonary parenchyma.7 The Respiratory System 7 small conducting airways ranging in diameter from three to less than one millimetre. while the supplying structures. which produce secretions.722 square feet) of internal surface area of the tissue compartment. capable of narrowing the airway. an adult human lung has about 300 million alveoli. The walls of the bronchioles lack cartilage and seromucous glands. The airways are then called alveolar ducts and. and vice versa. the frequency of alveolar outpocketings increases rapidly. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. Whereas air and blood are continuously replenished. in the last generation. conductive airways. through the 160 square metres (about 1. The respiratory gases diffuse from air to blood. and non-capillary blood vessels belong to the non-parenchyma. The Gas-Exchange Region The gas-exchange region comprises three compartments: air. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. They are polyhedral structures. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. alveolar sacs. lymphatics. On average. with a 34 . Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. Distally. the whole wall is formed by alveoli. and tissue. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles.
and open on one side. On top of the epithelium. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. Ultimately. covers the remaining surface.7 Anatomy and Function of the Human Respiratory System 7 diameter of about 250 to 300 micrometres. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing. the thin air–blood barrier for gas exchange. the type I pneumocyte. The alveolar wall. called the interalveolar septum. The interalveolar septum is covered on both sides by the alveolar epithelial cells. These granules are the conspicuous ultrastructural features of this cell type. and a skeleton of connective tissue fibres. or cell debris originating from cell damage or normal cell death. Type II pneumocytes produce a surface-tension-reducing material. and their task is to keep the air–blood barrier clean and unobstructed. It contains connective tissue and interstitial 35 . The type I cells form. squamous cell type. together with the endothelial cells. It contains a dense network of capillaries. more cuboidal cell type. They are large cells. the type II pneumocyte. Before it is released into the airspaces. alveolar macrophages creep around within the surfactant fluid. covers between 92 and 95 percent of the gas-exchange surface. the alveolar macrophages are derived from the bone marrow. whereas type II cells are secretory. is common to two adjacent alveoli. and their cell bodies abound in granules of various content. the smallest of the blood vessels. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. a second. where they connect to the airway. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. A thin. partly foreign material that may have reached the alveoli. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. the pulmonary surfactant.
On each side. After numerous divisions. low in oxygen content but laden with carbon dioxide. Blood. the respiratory gases must diffuse across longer distances. As a consequence. which have on average a pressure five times lower than systemic arteries. The fibroblasts are thought to control capillary blood flow or. Because intravascular pressure determines the arterial wall structure. which seem to be endowed with contractile properties. Lymphatic Vessels. and proper functioning of the lung is severely jeopardized. alternatively. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. and cells (mainly fibroblasts). Blood Vessels.7 The Respiratory System 7 fluid. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. the pulmonary arteries. an excess of fluid accumulates in the lung tissue and within the airspaces. to prevent the accumulation of extracellular fluid in the interalveolar septa. are much flimsier than systemic arteries of corresponding size. The oxygenated blood from the capillaries is collected by 36 . amorphous ground substance. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. This pathological condition is called pulmonary edema. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. The connective tissue comprises a system of fibres. the lung is a complex organ. and Nerves With respect to blood circulation. is carried from the right heart through the pulmonary arteries to the lungs. following relatively closely the course of the dividing airway tree.
called bronchomediastinal trunks. originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. Within the lung and the mediastinum. The superficial. They are small vessels and generally do not reach as far into the periphery as the conducting airways. they end several generations short of the terminal bronchioles. The deep lymphatic system originates around the conductive airways and arteries and converges into vessels that mostly follow the bronchi and arterial vessels into the mediastinum.7 Anatomy and Function of the Human Respiratory System 7 venules and drained into small veins. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. With a few exceptions. The bronchial arteries originate from the aorta or from an intercostal artery. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. however. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. Small bronchial veins exist. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. Finally. The interlobular veins then converge on the intersegmental septa. Generally. Lymph drainage 37 . four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. Most of their blood is naturally collected by pulmonary veins.
The Respiratory System
paths from the lung are complex. The precise knowledge of their course is clinically relevant, because malignant tumours of the lung spread via the lymphatics. The pleurae, the airways, and the vessels are innervated by afferent and efferent fibres of the autonomic nervous system. Parasympathetic nerve fibres from the vagus nerve (10th cranial nerve) and sympathetic branches of the sympathetic nerve trunk meet around the stem bronchi to form the pulmonary autonomic nerve plexus, which penetrates into the lung along the bronchial and vascular walls. The sympathetic fibres mediate a vasoconstrictive action in the pulmonary vascular bed and a secretomotor activity in the bronchial glands. The parasympathetic fibres stimulate bronchial constriction. Afferent fibres to the vagus nerve transmit information from stretch receptors, and those to the sympathetic centres carry sensory information (e.g., pain) from the bronchial mucosa.
After early embryogenesis, during which the lung primordium is laid down, the developing human lung undergoes four consecutive stages of development, ending after birth. The names of the stages describe the actual morphology of the prospective airways. The pseudoglandular stage exists from 5 to 17 weeks; the canalicular stage, from 16 to 26 weeks; the saccular stage, from 24 to 38 weeks; and finally the alveolar stage, from 36 weeks of fetal age to about 1 ½ to 2 years after birth. The lung appears around the 26th day of intrauterine life as a ventral bud of the prospective esophagus. The bud separates distally from the gut, divides, and starts to grow into the surrounding mesenchyme. The epithelial components of the lung are thus derived from the gut (i.e., they
Anatomy and Function of the Human Respiratory System
are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.
The Respiratory System
The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.
CONTROL AND MECHANICS OF BREATHING
he respiratory system is intimately associated with the brain and central nervous system. Indeed, the diaphragm and the muscles of the chest are innervated by neurons that connect to regions of the brain known as the pons and medulla oblongata. These regions are involved in the control of autonomic nervous activity and therefore regulate internal organs without any conscious recognition or effort. Thus, breathing is an automated function in which nerve impulses sent from the brain stimulate the respiratory muscles to contract, thereby producing the mechanical forces associated with inhalation and exhalation. These impulses give rise to every breath, and in healthy individuals they are sent faithfully for life.
control of breathing
Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. The respiratory rhythm and the length of each phase of respiration are set by reciprocal stimulatory and inhibitory interconnection of these brain-stem neurons. An important characteristic of the human respiratory system is its ability to adjust breathing patterns to changes in both the internal milieu and the external environment. Ventilation increases and decreases in proportion to
the force of respiratory muscle contraction. they also complicate the regulation of breathing. Although the diaphragm is the major muscle of breathing. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. In addition. chewing and swallowing. These same muscles are used to perform a number of other functions. such as speaking. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. Mechanoreceptors monitor the expansion of the lung. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. Intercostal muscles inserting on the ribs. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. such as the airway narrowing that occurs in an asthmatic attack. and the extent of muscle shortening. and muscles such as the scalene and sternocleidomastoid that attach both to the ribs and to the cervical spine at the base of the skull also play an important role in the exchange of air between the atmosphere and the lungs.7 The Respiratory System 7 swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. and maintaining posture. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement. breathing can be 42 . Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. the size of the airway. abdominal muscles. laryngeal muscles and muscles in the oral and nasal pharynx adjust the resistance of movement of gases through the upper airways during both inspiration and expiration. This flexibility in breathing patterns in large part arises from sensors distributed throughout the body that send signals to the respiratory neuronal networks in the brain.
com 43 . Shutterstock.7 Control and Mechanics of Breathing 7 Singing demands a strong diaphragm to control breath.
inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . allowing the activity of these physiological systems to be coordinated with respiration. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. Input into the respiratory control system from higher brain centres may help optimize breathing so that not only are metabolic demands satisfied by breathing but ventilation also is accomplished with minimal use of energy. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. which supply the diaphragm and other thoracic and abdominal muscles. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. Neurally. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. in turn they drive cranial motor neurons.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla.
There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity. early inspiratory. After a gap of a few milliseconds. This type of breathing. Offswitch neurons in the medulla terminate inspiration.7 Control and Mechanics of Breathing 7 abruptly. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. As the activity of the post-inspiratory neurons subsides. Then the cycle begins again. offswitch. post-inspiratory. and expiratory. is called apneustic breathing. It is believed by some that these post-inspiratory neurons have inhibitory effects on both inspiratory and expiratory neurons and therefore play a significant role in determining the length of the respiratory cycle and the different phases of respiration. When the vagus nerves are sectioned or pontine centres are destroyed. which occasionally occurs in persons with diseases of the brain stem. and gradually declines until the onset of expiratory neuron activity. This increase in activity. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. inspiratory activity is restarted. which produces lung expansion. Mechanically. expiratory neurons discharge and inspiratory neurons are strongly inhibited. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. but at a much lower level. although in upright humans the lower expiratory intercostal muscles 45 . breathing is characterized by prolonged inspiratory activity that may last for several minutes.
more expiratory intercostal and abdominal muscles contract. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. Increased activity of chemoreceptors caused by hypoxia or an increase in the partial pressure of carbon dioxide augments both the rate and depth of breathing. for example. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. or the reduction of oxygen supply to tissues to less than physiological levels (produced. as the demand to breathe increases (for example. cheMoreceptors One way in which breathing is controlled is through feedback by chemoreceptors.7 The Respiratory System 7 and the abdominal muscles may be active even during quiet breathing. which restores partial pressures of oxygen and carbon dioxide to their usual levels. During sleep and anesthesia. Peripheral Chemoreceptors Hypoxia. by a 46 . the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. with exercise). As expiration proceeds. too much ventilation depresses the partial pressure of carbon dioxide. Ventilation levels behave as if they were regulated to maintain a constant level of carbon dioxide partial pressure and to ensure adequate oxygen levels in the arterial blood. Conversely. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. Moreover. and central chemoreceptors in the brain. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood.
The amplitude of these fluctuations. as reflected in the size of carotid body signals. unlike type II cells. This organ is extraordinarily well perfused and responds to changes in the partial pressure of oxygen in the arterial blood flowing through it rather than to the oxygen content of that blood (the amount of oxygen chemically combined with hemoglobin). catecholamines. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. contain electron-dense vesicles. and the carotid body senses these fluctuations. Microscopically. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. stimulates the carotid and aortic bodies. In addition to responding to hypoxia. The type II cells are generally not believed to have a direct role in chemoreception. Acetylcholine. responding more to rapid than to slow changes in the partial pressure of carbon dioxide. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls.7 Control and Mechanics of Breathing 7 trip to high altitudes). and neuropeptides such as enkephalins. may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. This arterial blood parameter rises and falls as air enters and leaves the lungs. a branch of the glossopharyngeal nerve. which. vasoactive 47 . The type I cells are arranged in groups and are surrounded by type II cells. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. the carotid body consists of two different types of cells. The two carotid bodies are small organs located in the neck at the bifurcation of each of the two common carotid arteries into the internal and external carotid arteries. the principal arterial chemoreceptors. Fine sensory nerve fibres are found in juxtaposition to type I cells.
The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. Current thinking places these receptors near the undersurface (ventral part) of the 48 . It is believed that hypoxia and hypercapnia (excessive carbon dioxide in the blood) cause the release of one or more of these neuroactive substances from the type I cells. which then act on the sensory nerve. Carbon dioxide increases the acidity of the fluid surrounding the cells but also easily passes into cells and thus can make the interior of cells more acidic. The aortic bodies located near the arch of the aorta also respond to acute changes in the partial pressure of oxygen. and substance P. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. ventilation increases nearly linearly. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen.7 The Respiratory System 7 intestinal peptide. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. inhaling gases that contain carbon dioxide stimulates breathing. As the partial pressure of carbon dioxide in arterial blood rises. are located within the vesicles. Even if both the carotid and aortic bodies are removed. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide.
Stimulation of these receptors. which excites stretch receptors in the airways. in the respiratory muscles measure muscle length and increase motor discharge to the diaphragm and intercostal muscles when increased stiffness of the lung or resistance to the movement of air caused by disease impedes muscle shortening. 49 . Generally. there is a length at which the force generated is maximal. because they can help maintain tidal volume and ventilation at normal levels. Receptors. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves.7 Control and Mechanics of Breathing 7 medulla. Some investigators argue that respiratory responses produced at the ventral medullary surface are direct and are caused by interference with excitatory and inhibitory inputs to respiration from these vasomotor neurons. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. Changes in the length of a muscle affect the force it can produce when stimulated. Tendon organs. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. monitor changes in the force produced by muscle contraction. Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. called spindles. another receptor in muscles. These receptors are particularly important when lung function is impaired. The Hering-Breuer reflex is initiated by lung expansion.
and thus breathing typically becomes lighter. The most important function of these receptors. the association between sleep and breathing is more complicated than this because brain activity changes as a person progresses through the different stages of sleep. However. increased levels of oxygen are needed to fuel muscle function. during sleep. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. the reflex allows inspiratory time to be lengthened. others (the J receptors) by unmyelinated fibres. the body’s metabolic rate slows. these receptors constrict the airways and cause rapid shallow breathing. like the stretch receptors. For example. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. accelerating the frequency of breathing. and prostaglandins. may be to defend the lung against noxious material in the atmosphere. When stimulated. Variations in breathing Variations in breathing result from changes in metabolic demands in the tissues of the body. however. during exercise. 50 . by the vagus nerve. which inhibits the penetration of injurious agents into the bronchial tree.7 The Respiratory System 7 which send signals to the medulla by the vagus nerve. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. shortens inspiratory times as tidal volume (the volume of air inspired) increases. This in turn leads to fluctuations in breathing patterns. bradykinin. At the opposite end of the spectrum. Stimulation of irritant receptors also causes coughing. These receptors are supplied. When lung inflation is prevented. helping to preserve tidal volume.
Sources of these signals include mechanoreceptors in the exercising limbs. and thermal receptors. thus preserving acid–base homeostasis.7 Control and Mechanics of Breathing 7 Exercise One of the remarkable features of the respiratory control system is that ventilation increases sufficiently to keep the partial pressure of carbon dioxide in arterial blood nearly unchanged despite the large increases in metabolic rate that can occur with exercise. Shutterstock. and thermal receptors all work in concert during exercise to enhance ventilation. the arterial chemoreceptors. because body temperature rises as metabolism increases. arterial chemoreceptors. Mechanoreceptors. A number of signals arise during exercise that can augment ventilation. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide.com 51 .
The effects on ventilatory pattern vary with sleep stage. It remains unclear. In slow-wave sleep. breathing can become quite erratic. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. 52 . The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. but it may entail unstable feedback regulation of breathing. but there is an even greater decline in ventilation so that the partial pressure of carbon dioxide in arterial blood rises slightly and arterial partial pressure of oxygen falls. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe.7 The Respiratory System 7 The brain also seems to anticipate changes in the metabolic rate caused by exercise. breathing is diminished but remains regular. Changes in the concentration of potassium and lactic acid in the exercising muscles acting on unmyelinated nerve fibres may be another mechanism for stimulation of breathing during exercise. body metabolism is reduced. with intermittent periods of apnea. Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. or even apnea (cessation of breathing). Sleep During sleep. whereas in rapid eye movement sleep. This rhythmic waxing and waning of breathing. after the physicians who first described it. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. however. is called Cheyne-Stokes breathing. During sleep. how these various mechanisms are adjusted to maintain acid–base balance.
When the air pressure within the alveolar spaces falls below atmospheric pressure. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways. and in the obese. air is blown from the lungs (expiration). in males. Snoring and disturbed behaviour during sleep may also occur. flow is determined by how 53 . and complaints of excessive daytime drowsiness are common. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. Others. sleep is of poor quality. When the air pressure within the alveoli exceeds atmospheric pressure. however. which increase the likelihood of obstruction. this intermittent obstruction occurs repeatedly during the night. have normal upper airway anatomy. undergo phasic changes in their electrical activity synchronous with respiration. the Mechanics of breathing Air moves in and out of the lungs in response to differences in pressure. provided the larynx is open. in the newborn. leading to severe drops in the levels of blood oxygenation. termed sleep apnea syndrome. Because arousal is often associated with the termination of episodes of obstruction. Because atmospheric pressure remains relatively constant. Many of the upper airway muscles. occurs most commonly in the elderly. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. In some persons with sleep apnea syndrome. In some individuals. air enters the lungs (inspiration).7 Control and Mechanics of Breathing 7 In addition. like the tongue and laryngeal adductors. The condition. and the reduced activity of these muscles during sleep may lead to upper airway closure. portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids.
Encyclopædia Britannica. forcing air in and out of the lungs. the volume of chest and lungs 54 . Inc. and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume. Each small increment of expansion transiently increases the space enclosing lung air. less air per unit of volume in the lungs and pressure falls. Alveolar pressure fluctuations are caused by expansion and contraction of the lungs resulting from tensing and relaxing of the muscles of the chest and abdomen. When the muscles of inspiration relax. A difference in air pressure between atmosphere and lungs is created.7 The Respiratory System 7 The diaphragm contracts and relaxes. therefore. much above or below atmospheric pressure the pressure within the lungs rises or falls. There is.
The Lung–Chest System The forces that normally cause changes in volume of the chest and lungs stem not only from muscle contraction but from the elastic properties of both the lung and the chest. thereby allowing the lung to separate from the chest at this particular spot. therefore. A lung is similar to a balloon in that it resists stretch. lung air becomes transiently compressed. This. The pressure measured in the small pleural space so created is substantially below atmospheric pressure at a time when the pressure within the lung itself equals atmospheric pressure. then. resulting in flow of air into or out of the lung and establishment of a new lung volume. its pressure rises above atmospheric pressure. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. This tendency of the lung to collapse or pull away from the chest is measurable by carefully placing a blunt needle between the outside of the lung and the inside of the chest wall. The force also increases in proportion to the rapidity with which air is drawn into the lung and decreases in proportion to the force with which air is expelled from the lungs. In summary. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. This negative (below-atmospheric) pressure is a measure. of the force required to keep the lung distended. the pleural pressure reflects primarily two forces: 55 .7 Control and Mechanics of Breathing 7 decreases. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside.
Because the pleural pressure is below atmospheric pressure. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. thereby further raising the diaphragm and causing forceful expiration. which are in turn stretched inward by the pull of the lungs. the force required to cause airflow in and out of the lung. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. When these muscles relax. This additional muscular force is removed on relaxation 56 . The Role of Muscles The respiratory muscles displace the equilibrium of elastic forces in the lung and chest in one direction or the other by adding muscular contraction. these would collapse. Were it not for the outward traction of the chest on the lungs. The lung– chest system thus acts as two opposed coiled springs. as by a wound or by a surgical incision.7 The Respiratory System 7 1. the force required to keep the lung inflated against its elastic recoil and 2. the additional retraction of lung returns the system to its equilibrium position. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. the length of each of which is affected by the other. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch. And were it not for the inward traction of the lungs on the chest and diaphragm. During inspiration.
The respiratory pump is versatile. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. Pressures 57 . The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. The volume in these circumstances is known as the residual volume.154 cubic inches) per minute in adults. The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. capable of increasing its output 25 times. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. such as pieces of glass. separated by a film of water. expiration being accomplished “passively” by elastic recoil of the lung. During ordinary breathing. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). muscular contraction occurs only on inspiration. At total relaxation of the muscles of inspiration and expiration.
com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. Airflow velocity. can be raised voluntarily to 400 litres per minute.e..8 pounds per square inch) by the so-called Valsalva maneuver—a forceful contraction of the chest and abdominal muscles against a closed glottis (i. with no space between the vocal cords).7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles. normally reaching 30 litres per minute in quiet breathing.istockphoto. The beating of cilia (hairline projections) from cells lining the airways 58 . © www . Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.
7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. and seven litres. totaling about 0. 59 . Normal lungs. An infant takes 33 breaths per minute with a tidal volume (the amount of air breathed in and out in one cycle) of 15 millilitres. In fact. however. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. 500 millilitres. respectively. such adherence occasionally does occur and is one of the dreaded complications of premature births. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths.
whereas the carbon dioxide is expelled from the alveoli during exhalation. about 0. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. 60 . The structure of the human lung provides an immense internal surface that facilitates gas exchange between the alveoli and the blood in the pulmonary capillaries. gas exchange Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs.722 square feet). This process of adaptation is necessary to maintain normal physiological function. as well as other organ systems. transfer carbon dioxide to the alveoli. At high altitudes or during activities such as deep-sea diving. or ¹/¹00 of the diameter of a human hair. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and. The oxygen is then distributed by the blood to the tissues. Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane. in exchange. adapt to variations in atmospheric pressure.CHAPTER3 GAS EXCHANGE AND RESPIRATORY ADAPTATION I nhaled air is rich in oxygen. which is needed to support the functions of the body’s various tissues. For inhaled oxygen to reach these tissues.5 micrometre. the respiratory system. however. The area of the alveolar surface in the adult human is about 160 square metres (1.
com 61 .7 Gas Exchange and Respiratory Adaptation 7 Changes in the atmosphere’s pressure occur when deep-sea diving and require the respiratory system to adapt. Shutterstock.
convection and diffusion. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. which in turn is responsive to overall body requirements. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. A gas will diffuse from an area of greater partial pressure to an area of lower partial pressure regardless of the distribution of the partial pressures of other gases. for example. Diffusion is the primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. or mass flow. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. Convection. The performance of the heart and circula- 62 . as occurs. caused by differing modes of transport in the blood. The rapidity of circulation is determined by the output of the heart. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. the partial pressure of each gas is directly proportional to its concentration. but almost equal quantities of the two gases are involved in metabolism and gas exchange. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. in the flow through skeletal muscles during exercise. Respiratory gases also move by diffusion across tissue barriers such as membranes. In a mixture of gases. The partial pressure of a gas in fluid is a measure of its tendency to leave the fluid when exposed to a gas or fluid that does not contain that gas. Local flows can be increased selectively.
which make up 40 to 50 percent of the blood volume in most mammals. The curve representing the content of oxygen in blood at various partial pressures of oxygen. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. is a characteristic S-shape because binding of oxygen to one iron atom influences the ability of oxygen to bind to other iron sites. Enough hemoglobin is present in normal human blood to permit transport of about 0. so less than 2 percent of oxygen is transported dissolved in plasma. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. Each iron atom can bind and then release an oxygen molecule. plays little role in oxygen exchange but is essential to carbon dioxide exchange. the cell-free. Plasma. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. Not all of the oxygen transported in the blood is transferred to the tissue cells. important determinants of gas transport. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). called the oxygen-dissociation curve. Most oxygen is bound to hemoglobin. a protein contained within red cells. These systems are present mainly in the red cells.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. In alveoli at sea level. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed.2 ml of oxygen per ml of blood. The amount of oxygen 63 . liquid portion of blood. transport of oxygen Oxygen is poorly soluble in plasma. therefore.
carbon dioxide. including hydrogen ions (which determine the acidity. Because of this decreased affinity. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. or pH.3-DPG. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. A rightward shift of the curve is thought to be of benefit in releasing oxygen to the tissues when needs are great in relation to oxygen delivery. Reductions in normal concentrations of hydrogen ions. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. This reserve is available to meet increased oxygen demands. carbon dioxide. carbon dioxide.3-DPG result in an increased affinity of hemoglobin for oxygen. and the oxygen-dissociation curve shifts to the right. and 2. Hemoglobin binds not only to oxygen but to other substances as well.3-DPG decrease the affinity of hemoglobin for oxygen.) Increases in hydrogen ions.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure.3-diphosphoglycerate (2. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. Although these substances do not bind to hemoglobin at the oxygen-binding sites. At rest. as occurs with anemia or extreme exercise. and 2. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). Conversely. (Affinity denotes the tendency of molecules of different species to bind to one another. or 2. with the binding of oxygen. of the blood). venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. and the curve is shifted 64 . a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure).
whereas a decrease in temperature shifts the curve to the left (increased affinity). 65 . enhanced release of oxygen). principally hemoglobin. about 5 percent. so that temperature-associated changes in oxygen affinity have little physiological importance. remains unchanged and is transported dissolved in blood. The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. Complete elimination would lead to large changes in acidity between arterial and venous blood. to form a compound known as carbamate. Temperature changes affect the oxygen-dissociation curve similarly. The remainder is found in reversible chemical combinations in red blood cells or plasma. Furthermore. Some carbon dioxide binds to blood proteins. An increase in temperature shifts the curve to the right (decreased affinity. with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. This displacement increases oxygen binding to hemoglobin at any given partial pressure of oxygen and is thought to be beneficial if the availability of oxygen is reduced. A small portion of carbon dioxide. The range of body temperature usually encountered in humans is relatively narrow. transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. as occurs at extreme altitude. an insufficient time to eliminate all carbon dioxide.7 Gas Exchange and Respiratory Adaptation 7 to the left. blood normally remains in the pulmonary capillaries less than a second.
Carbonic anhydrase. inactivating them. are effective buffering agents. which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-). Blood acidity is minimally affected by the released hydrogen ions because blood proteins. it combines with water to form carbonic acid (H2CO3 ). especially hemoglobin. a protein enzyme present inside the 66 .7 The Respiratory System 7 Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water. essentially.com Carbon dioxide enters blood in the tissues because its local partial pressure is greater than its partial pressure in blood flowing through the tissues.) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. a relatively weak acid. Shutterstock. (A buffer solution resists change in acidity by combining with added hydrogen ions and. As carbon dioxide enters the blood.
known as the chloride shift. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. The capacity of blood to carry carbon dioxide as bicarbonate is enhanced by an ion transport system inside the red blood cell membrane that simultaneously moves a bicarbonate ion out of the cell and into the plasma in exchange for a chloride ion. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. that is. Thus. permits the plasma to be used as a storage site for bicarbonate without changing the electrical charge of either the plasma or the red blood cell. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change 67 . then transported to the plasma. A few amino sites on hemoglobin are oxylabile. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. Because the enzyme is present only inside the red blood cell. however. while 62 percent exists as bicarbonate in plasma. The bulk of bicarbonate ions is first produced inside the cell. The simultaneous exchange of these two ions. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. A reverse sequence of reactions occurs when blood reaches the lung. where the partial pressure of carbon dioxide is lower than in the blood. The change in molecular configuration of hemoglobin that accompanies the release of oxygen leads to increased binding of carbon dioxide to oxylabile amino groups.7 Gas Exchange and Respiratory Adaptation 7 red blood cell.
most carbon dioxide is transported as bicarbonate or carbamate. yet this pool is important. and almost all blood entering the lungs participates in gas exchange. Between these two events. blood flow through the lung is continuous. because only free carbon dioxide easily crosses biologic membranes. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. Virtually every molecule of carbon dioxide produced by metabolism must exist in the free form as it enters blood in the tissues and leaves capillaries in the lung. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. The lower parts of the lung receive slightly more blood flow than ventilation because gravity has a greater effect on the distribution of blood than on the distribution of inspired air. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. because of the increased size of inspired breaths. Under ideal circumstances. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. not all inspired air participates in gas exchange.7 The Respiratory System 7 or binding. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 . In contrast to the cyclic nature of ventilation. In health. gas exchange in the lung The introduction of air into the alveoli allows the removal of carbon dioxide and the addition of oxygen to venous blood.
venous blood enters the bloodstream without passing through functioning lung tissue. shunting. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. and limitations of diffusion. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e.g. If the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange—a condition known as hypoventilation—the alveolar partial pressure of carbon dioxide rises and the partial pressure of oxygen falls almost reciprocally. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. This abnormality leads to parallel changes in both gas and blood and is the only abnormality in gas exchange that does not cause an increase in the normally small difference between arterial and alveolar partial pressures of oxygen. but the level of carbon dioxide in arterial blood is not elevated even 69 . A reduction in arterial blood oxygenation is seen with shunting. Because of the differences in oxygen and carbon dioxide transport. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small.7 Gas Exchange and Respiratory Adaptation 7 gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. In shunting. alveoli filled with fluid or inflammatory material). ventilation– blood flow imbalance..
When blood perfusing the collapsed. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal. The differing effects of shunting on oxygen and carbon dioxide partial pressures are the result of the different configurations of the blood-dissociation curves of the two gases. Because the carbon dioxide–dissociation curve is steep and relatively linear. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. In contrast. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. which is usually achieved without difficulty. and the composite arterial blood carbon dioxide content remains normal. As a result. compensation for decreased carbon dioxide exchange in one portion of the lung can be counterbalanced by increased excretion of carbon dioxide in another area of the lung. the content of carbon dioxide is greater than the normal carbon dioxide content. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. Blood leaving an unventilated area of the lung has 70 . The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. As noted earlier.7 The Respiratory System 7 though the shunted blood contains more carbon dioxide than arterial blood. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung.
and an increase in blood partial pressure results in a negligible increase in oxygen content. and each alveolus receives approximately equal quantities of both. therefore. a plateau is reached at the 71 . cannot compensate in terms of greater oxygenation for underventilated alveoli because. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. alveoli become either overventilated or underventilated in relation to their blood flow. In the healthy area of the lung. in the arterial blood. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. however. Mixture of blood from this healthy portion of the lung (with normal oxygen content) and blood from the abnormal area of the lung (with decreased oxygen content) produces a composite arterial oxygen content that is less than the normal level. Thus. reaches a plateau at the normal alveolar partial pressure. Inspired air and blood flow normally are distributed uniformly. the amount of carbon dioxide eliminated is increased. This effect on blood oxygenation is seen not only in shunting but in any abnormality that results in a localized reduction in blood oxygen content. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. Overventilated alveoli.7 Gas Exchange and Respiratory Adaptation 7 an oxygen content that is less than the normal content. In alveoli that are overventilated. The oxygen-dissociation curve. an area of healthy lung cannot counterbalance the effect of an abnormal portion of the lung on blood oxygenation because the oxygen-dissociation curve reaches a plateau at a normal alveolar partial pressure of oxygen. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. however.
For oxygen. however. loss of surface area available for diffusion of oxygen. 72 . A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. In healthy lungs there is a narrow distribution of the ratio of ventilation to blood flow throughout the lung that is centred around a ratio of 1 to 1.7 The Respiratory System 7 alveolar partial pressure of oxygen. Carbon dioxide exchange. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. is not affected by an abnormal ratio of ventilation and blood flow as long as the increase in ventilation that is required to maintain carbon dioxide excretion in overventilated alveoli can be achieved. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. which facilitates carbon dioxide exchange. and increased ventilation will not increase blood oxygen content. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. the greater the reduction in blood oxygenation. a reduction in the alveolar partial pressure of oxygen required for diffusion. A variety of processes can interfere with this orderly exchange. and decreased time available for exchange due to increased velocity of flow. these include increased thickness of the alveolar–capillary membrane. In disease.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. These factors are usually grouped under the broad description of “diffusion limitation.
the heart was regarded as a furnace where the “fire of life” kept the blood boiling.7 Gas Exchange and Respiratory Adaptation 7 interplay of respiration. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). where. To recharge the molecule by adding the third phosphate group requires energy derived from 73 . such as the contraction of muscle fibre proteins or the synthesis of protein molecules. circulation. whose third phosphate bond can release a quantum of energy to fuel many cell processes. which set the limit for respiration. and MetabolisM The interplay of respiration. through the oxidation of foodstuffs such as glucose. The precise object of respiration therefore is the supply of oxygen to the mitochondria. Modern cell biology has unveiled the truth behind the metaphor. and metabolism is the key to the functioning of the respiratory system as a whole. the energetic needs of the cells are supplied. cells set the demand for oxygen uptake and carbon dioxide discharge. For gas exchange that takes place in the lungs. The proper functioning of the respiratory system depends on both the ability of the system to make functional adjustments to varying needs and the design features of the sequence of structures involved. In antiquity and the medieval period. ATP is degraded to adenosine diphosphate (ADP). The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. Each cell maintains a set of furnaces. the mitochondria. In the process. The circulation of the blood links the sites of oxygen use and uptake. This involves transport of oxygen from the lung to the tissues by means of the circulation of blood. circulation. a molecule with only two phosphate bonds.
which operates in the absence of oxygen. will die. or its need for oxygen. transferred to blood in the lungs. aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. which requires oxygen and involves the mitochondria. and 2. In contrast. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. Because oxidative phosphorylation occurs only in mitochondria. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. many cells. or substrates. It begins with 74 . Two pathways are available: 1. Oxygen is collected from environmental air. For any sustained highlevel cell activity. the aerobic metabolic pathway is therefore preferable. aerobic metabolism. or fermentation. or even the organism. The anaerobic pathway leads to acid waste products and is wasteful of resources: the breakdown of one molecule of glucose generates only two molecules of ATP. whereas they usually have a reasonable supply of substrates in stock. If oxygen supply is interrupted for a few minutes.7 The Respiratory System 7 the breakdown of foodstuffs. and since each cell must produce its own ATP (it cannot be imported). anaerobic glycolysis. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. because the cells maintain only a limited store of highenergy phosphates and of oxygen. the number of mitochondria in a cell reflects its capacity for aerobic metabolism.
essentially resulting from a higher heart rate. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. This is accompanied by an increased cardiac output. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. Blood also serves as carrier for both respiratory gases: oxygen. Metabolism. but a highly trained athlete may achieve a more than 20-fold increase. or. more accurately the metabolic rate of the cells. which is determined by its content of hemoglobin in the red blood cells. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. At rest. which is bound to hemoglobin in the red blood cells.5 micrometre) and the surface area of the barrier. a human consumes about 250 ml of oxygen each minute. In the most peripheral airways. As more and more muscle cells become engaged in doing work. which is achieved by convection or mass flow of air through an ingeniously branched system of airways. transport by blood flow. and carbon dioxide.7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. and by 75 . the demand for ATP and oxygen increases linearly with work rate. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. and discharge to the cells. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. With exercise this rate can be increased more than 10-fold in a normal healthy individual. which is carried by both plasma and red blood cells and which also serves as a buffer for acid–base balance in blood and tissues. sets the demand for oxygen.
such as dogs or horses. Muscle can do more work. the athletic species in nature. from the lung to the mitochondria. Much has been learned from comparative physiology and morphology. but it is not straightforward. because of the complexity of the system. accumulate and limit the duration of work. this is called adaptive variation. well below interspecies differences. Furthermore. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. Consequently. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. a feature called allometric variation. the aerobic scope can be increased by training in an individual. For example. oxygen consumption per unit body mass increases as animals become smaller. have an aerobic scope more than twofold greater than that of other animals of the same size. but beyond the aerobic scope they must revert to anaerobic metabolism.7 The Respiratory System 7 increased ventilation of the lungs. Then. mainly lactic acid. These dynamic adjustments to the muscles’ needs occur up to a limit that is twice as high in the athlete as in the untrained individual. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. The limit to oxidative metabolism is therefore set by some features of the respiratory system. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. with the result that waste products. based on observations that oxygen consumption rates differ significantly among species. 76 .
7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. cardiac output is augmented by increasing heart rate. Mitochondria set the demand for oxygen. the muscle cells make more mitochondria. For example. the mitochondria increase in proportion to the augmented aerobic scope.com Within the aerobic scope the adjustments are caused by functional variation. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. Shutterstock. 77 . In training. in all types of variation. This difference arises from a phenomenon known as adaptive variation. If energy (ATP) needs to be produced at a higher rate.
If this proves true. It appears. rate. mainly the heart. the levels of hemoglobin in the blood. physiological changes are more acute in nature and are influenced by the immediate affects of decreased ventilation or by the affects of increased hydrostatic pressure on the body. adaptations Adaptation of the respiratory system to different atmospheric pressures plays a fundamental role in maintaining the efficiency of gas exchange and gas transport in the blood. whereas the mitochondria. the lung lacks this capacity to adapt. however. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake.7 The Respiratory System 7 It is thus possible that oxygen consumption is limited at the periphery. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. whose capacity to pump blood reaches a limit. the blood vessels. which determines the volume of blood that can be pumped with each stroke. the lung may well constitute the ultimate limit for the respiratory system. In the case of adaptation to high altitudes. such as in training. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. and the heart can increase in number. the structure of the alveoli in the lungs. In the cases of swimming and diving. or volume to augment their capacity when energy needs increase. beyond which oxidative metabolism cannot be increased by training. 78 . But. the blood. both in terms of rate and of the size of the ventricles. The issue of peripheral versus central limitation is still under debate. at the last step of aerobic metabolism.
both in the ambient air and in the alveolar spaces of the lung. Barry C. whether undertaken deliberately or not.7 Gas Exchange and Respiratory Adaptation 7 High Altitudes Ascent from sea level to high altitude has well-known effects on respiration. such as cattle. commences from the time of exposure to high altitudes. Humans and some other mammalian species. Bishop/National Geographic/Getty Images 79 . Indigenous mountain species such as the At high altitudes. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. This very fall poses the major respiratory challenge to humans at high altitude. which. which heighten the partial pressure of oxygen at all stages. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen.
the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. on the other hand. which increases the amount of oxygen transported to the tissues.3DPG. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. exhibit an adaptation that is heritable and has a genetic basis. Diffusion of oxygen across the alveolar walls into the blood is facilitated. The initial response of respiration to the fall of oxygen partial pressure in the blood on ascent to high altitude occurs in two small nodules. from the alveolar spaces in the lung to the mitochondria in the cells. As the oxygen deprivation persists. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. attached to the division of the carotid arteries on either side of the neck. 80 . and. the size of muscle fibres decreases.7 The Respiratory System 7 llama. which takes the form of deeper breathing rather than a faster rate at rest. In addition. the carotid bodies enlarge but become less sensitive to the lack of oxygen. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. the carotid bodies. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. where oxygen is needed for the ultimate biochemical expression of respiration. the tissues develop more blood vessels. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages. With a prolonged stay at altitude. The low oxygen partial pressure in the lung is associated with thickening of the small blood vessels in pulmonary alveolar walls and a slight increase in pulmonary blood pressure. which also shortens the diffusion path of oxygen. such as 2. thought to enhance oxygen perfusion of the lung apices. as capillary density is increased.
alpaca. After living many years at high altitude. exhibit a set of responses that may be called a “diving reflex. Their hemoglobin has a high oxygen affinity. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude. This disease is characterized by greater levels of hemoglobin. Human respiration requires ventilation with air. after the Peruvian physician who first described it. Nevertheless. They do not develop small muscular blood vessels or an increased blood pressure in the lung. sometimes called Monge disease. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. all vertebrates.7 Gas Exchange and Respiratory Adaptation 7 Indigenous mountain animals like the llama. these indigenous. or benign tumour. some highlanders lose this acclimatization and develop chronic mountain sickness. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. A chemodectoma.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. and their carotid bodies remain small. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the 81 . Swimming and Diving Fluid is not a natural medium for sustaining human life after the fetal stage. and vicuña in the Andes or the yak in the Himalayas are adapted rather than acclimatized to the low oxygen partial pressures of high altitude. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. In contrast to acclimatized humans. Other physiological changes are also observed. including humans.
The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. At the depth of a diver. Two factors are involved.7 The Respiratory System 7 same time that a diver is breathing from an independent gas supply. but it cannot provide an equivalent increase in oxygen. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. the absolute pressure. but the oxygen content of the blood concurrently falls to unusually low levels. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. Unconsciousness may then occur in or under the water. many of them unique in human physiology. however. Divers who breathe from an apparatus that delivers gas at the same pressure as that of the surrounding water need not return to the surface to breathe and can remain at depth for prolonged periods. which is 82 . Hyperventilation can be dangerous. and consciousness remains unimpaired. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. When the accumulated carbon dioxide at last forces the swimmer to return to the surface. But this apparent advantage introduces additional hazards. as sometimes happens in snorkeling. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. and this danger is greatly increased if the swimmer descends to depth. Most hazards result from the environmental pressure of water. Hyperventilation. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath.
Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. The increased work of breathing. and the consequences of the uptake of respiratory gases into. Hypoxia may result from failure of the gas supply and may occur without warning. rather than cardiac or muscular performance. Alveolar oxygen levels can also be disturbed in diving. This may be compounded by an increased inspiratory content of carbon dioxide. The effects of pressure are seen in many processes at the molecular and cellular level and include the physiological effects of the increased partial pressures of the respiratory gases. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). The other factor.7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. is one factor. is the vertical hydrostatic pressure gradient across the body. More commonly. acting at any depth. The multiple effects of submersion upon respiration are not easily separated from one another or clearly distinguishable from related effects of pressure upon other bodily systems. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. is the limiting factor for hard physical work underwater. the levels of inspired oxygen are 83 . the blood and tissues of the diver. often with the formation of bubbles. the increased density of the respiratory gases. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. and their subsequent elimination from.
At a partial pressure greater than 1. High values of end-tidal carbon dioxide with 84 . inspired oxygen is therefore maintained at a partial pressure somewhere between 0. In mixed-gas diving.2 and 0.7 The Respiratory System 7 increased. like an anesthetic. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. Oxygen in excess can be a poison.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. has the additional advantage of providing a breathing gas of lesser density. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner.5 bar. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. approximately in proportion to the reciprocal of the square root of the increasing gas density. The use of hydrogen. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels.640 feet) in the sea and more than 680 metres (2. it may cause the rapid onset of convulsions. An ability to tolerate carbon dioxide may increase the work capacity of a diver at depth but also may predispose him to other consequences that are less desirable. At the extreme depths now attainable by humans— some 500 metres (1.5 bar (“surface equivalent value” = 150 percent). which in a mixture with less than 4 percent oxygen is noncombustible. provides a greater respiratory advantage for deep diving.
a condition that. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. resulting in less intrathoracic blood volume. More seriously. the expanding gas may rupture alveolar septa and escape into interstitial spaces. Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. possibly extending into the pericardium or into the neck. which represents the net effect of the external pressures and the effects of chest buoyancy. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest.7 Gas Exchange and Respiratory Adaptation 7 only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. if it occurs underwater. and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. Also. Unless vented. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). in which case more blood will be shifted into the thorax. The concept of a hydrostatic balance point within the chest. has proved useful in designing underwater breathing apparatuses. And whatever the orientation of the diver in the water. The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). This is a major cause of death among divers. or it may be effectively greater. Failure to exhale 85 . places the diver at great risk.
which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure. Inadequacy of diver decompression. Decompression sickness is caused by the formation of bubbles from gases that were dissolved in the tissues while the diver was at an increased environmental pressure. Other possible causes of pulmonary barotrauma include retention of gas by a diseased portion of lung and gas trapping due to dynamic airway collapse during forced expiration at low lung volumes. can result in a sometimes life-threatening condition known as decompression sickness. 86 . even from depths as shallow as 2 metres (6.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.6 feet).
various types of pneumonia. and may be highly contagious. with this division occurring at the anatomical level of the larynx. and molds.CHAPTER4 INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM I nfectious diseases are among the most common conditions affecting the human respiratory system. resulting in patient isolation. whether of the upper or lower respiratory tract. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. bacteria. and any condition of the bronchi and lungs. however. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues. Thus. including viruses. as considered here. tracheitis. requiring patient hospitalization. can be effectively treated with prescription antimicrobial drugs. sinusitis. Examples of severe lower respiratory infections include croup. and tuberculosis. upper respiratory infections include the common cold. In most cases. whereas lower respiratory infections include laryngitis. However. Legionnaire disease. pharyngitis. and tonsillitis. These diseases may be caused by a variety of agents. infectious diseases. Some conditions can cause extensive lung damage. 87 .
or drafts. sometimes spreads to the lower respiratory structures. People can carry the virus and communicate it without experiencing any of the symptoms themselves. and the 88 . In other cases. Incubation is short. an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. and reoviruses. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. and tonsils are frequently the site of both acute and chronic infections. however. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. More than 200 agents can cause symptoms of the common cold. chilled wet feet. however. but this is now known to be incorrect. Some of these infections may resolve on their own. respiratory syncytial viruses. Rhinoviruses. influenza. The viruses start spreading from an infected person before the symptoms appear. The cold is caught from exposure to infected people. usually one to four days. pharynx. are the most frequent cause. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract. The feeling was originally believed to have a cause-and-effect relationship with the disease. not from a cold environment. including parainfluenza. with little or no medication. and may cause secondary infections in the eyes or middle ears. These conditions occur in both children and adults and are readily spread through exposure to infected individuals.7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses.
If the virus penetrates more deeply into the upper respiratory tract. but lingering cough and postnasal discharge may persist for two weeks or more. Young children can contract between three and eight colds a year.7 Infectious Diseases of the Respiratory System 7 spread reaches its peak during the symptomatic phase. which respond by pouring out streams of clear fluid. yellow-green fluid that is full of the debris of dead cells. There is no effective antiviral agent available for the common 89 . coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. Symptoms may include sneezing. The usual duration of the illness is about five to seven days. The nasal discharge is the first warning that one has caught a cold. Diagnosis of a cold is usually made by medical history alone. There is usually no fever. but it is possible to take a culture for viruses. Cold symptoms vary from person to person. chills. inflammation of the nose (rhinitis). its activities irritate the nose’s cells. sore throat. It may result from the greater amount of time spent indoors. usually coming into contact with the infectious agents in day care centres or preschools. but the reason for this incidence is unknown. The sensory organs in the nose are stung by the inflammatory reaction. but in the individual the same symptoms tend to recur in succeeding bouts of infection. This fluid acts to dilute the virus and clear it from the nose. Coughing can be dry or produce amounts of mucus. and minor epidemics commonly occur throughout the winter. headaches. Once a virus becomes established on the respiratory surface of the nose. the clear fluid often changing to a thick. The incidence of colds peaks during the autumn. and nasal discharge. Symptoms abate as the host’s defenses increase. which increases the likelihood of close contact with those persons carrying cold viruses. fatigue. thereby setting up sneezing. a second method of expelling the virus.
but it can comprise sneezing. Shutterstock. fatigue.com 90 . chills. headaches. the common cold does not involve a fever. and nasal discharge.7 The Respiratory System 7 Usually. rhinitis. sore throat.
In treating nonviral sore throat. uvula.7 Infectious Diseases of the Respiratory System 7 cold. Inflammation usually involves the nasopharynx. Microbial agents producing soreness may remain localized or may spread (by way of lymph channels or the bloodstream) and produce such serious complications as rheumatic fever. as are antiseptic gargles. Therapy consists of treating the symptoms: relieving aches. or a reaction to certain drugs. For a viral sore throat. The illness can be caused by bacteria. which typically subside after one week. Generally. A sore throat may be a symptom of influenza or of other respiratory infections. Infection by 91 . soft palate. a result of irritation by foreign objects or fumes. administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. Sore Throat Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). and the tonsils may secrete pus and become swollen. the throat reddens. In many studies. fever. and parasites and by recognized diseases of uncertain causes. and tonsils. and nasal congestion. viruses. antibiotics are often effective. Pharyngitis Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. treatment is aimed at relieving symptoms. One of the greatest medical controversies in the past few decades has concerned the efficacy of vitamin C (ascorbic acid) in the prevention or treatment of the common cold. fungi. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. mycoplasmas.
is instituted. Chronic cases caused by irritants in the environment or by 92 . A number of other infectious diseases may cause pharyngitis. and irritability. headache. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. syphilis. and the cause of pharyngeal inflammation can be determined by throat culture. but the other symptoms may persist for another two to three days. Lymphatic tissue in the pharynx may also become involved. If a diagnosis of streptococcal infection is established by culture. nausea. Within approximately three days the fever leaves. swelling of lymph nodes. headache. and sore throat that last for 4 to 14 days. however. Purulent (pus-producing) sinusitis can occur. They cause fever. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. a pustulant fluid on the tonsils or discharged from the mouth. Sinusitis Sinusitis is acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses (the cavities in the bones that adjoin the nose). and meningitis. extremely sore throat that is felt during swallowing. and a slight fever. sometimes in children there are abdominal pain. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever.7 The Respiratory System 7 Streptococcus bacteria may be a complication arising from a common cold. including tuberculosis. appropriate antibiotic therapy. requiring treatment with antibiotics. diphtheria. usually with penicillin. Diagnosis is established by a detailed medical history and by physical examination. Viral pharyngitis infections also occur. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment.
If the infection persists. and sinus tenderness. Common symptoms include facial pain. It may also be caused by allergy to agents 93 . but the adjacent mouth and nose have a varied bacterial flora. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. infection can be established. The organisms usually involved are Haemophilus influenzae. Chronic sinusitis may follow repeated or neglected attacks of acute sinusitis.7 Infectious Diseases of the Respiratory System 7 impaired immune systems may require more extended treatment. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. persons with sinusitis are usually found to have an elevation in body temperature. the pus localized in any individual sinus may have to be removed by means of a minor surgical procedure known as lavage. Treatment of acute sinusitis is directed primarily at overcoming the infecting organism by the use of systemic antibiotics such as penicillin and at encouraging drainage of the sinuses by the use of vasoconstricting nose drops and inhalations. Staphylococcus aureus. nasal discharge. and many other penicillin-sensitive anaerobes. keeping the sinuses clean. Streptococcus pneumoniae. Normally the middle ear and the sinuses are sterile. headache. Under normal conditions. When ciliary function is damaged. On physical examination. Following a common cold. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. including surgery. The origin of acute sinus infection is much like that of ear infection. Streptococcus pyogenes. and fever following previous upper respiratory viral illness.
The symptoms of chronic sinusitis are a tendency to colds. The 94 . Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. isolation to protect others from the infection. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. In severe cases endoscopic surgery may be necessary to remove obstructions. and warm throat irrigations or gargles with a mild antiseptic solution. virulent bacteria may spread from the infected tonsil to the adjoining tissues. such as fungi or pollen.7 The Respiratory System 7 in the environment. The infection lasts about five days. fever. repeated or persistent sore throat. purulent nasal discharge. and enlarged lymph nodes on both sides of the neck. The symptoms are sore throat. and swollen lymph nodes in the neck. The treatment includes bed rest until the fever has subsided. The infection may extend upward into the nose. usually hemolytic streptococci or viruses. obstructed breathing. Tonsillitis Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. Locally. Pain is not a feature of chronic sinusitis. resulting in a peritonsillar abscess. loss of smell. sinuses. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. with or without heart involvement. trachea. and bronchi. If antibiotic therapy or repeated lavage do not alleviate the condition. malaise. and sometimes headache. and ears or downward into the larynx. evidenced by tonsillar enlargement. Repeated acute infections may cause chronic inflammation of the tonsils. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. difficulty in swallowing.
diphtheritic. which is a major cause of lung disease globally. Likewise. Laryngitis Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. pneumonia. Thus. secretes a thick mucous substance. and contains many 95 . adherent membrane. or syphilitic. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. the infectious disease tuberculosis. in trench mouth. Laryngitis is classified as simple. Usually the mucous membrane lining the larynx is the site of prime infection. steam. In diphtheria the tonsils are covered with a thick. Simple laryngitis is usually associated with the common cold or similar infections.7 Infectious Diseases of the Respiratory System 7 treatment in this case is surgical removal (tonsillectomy). For example. or sulfur dioxide can also cause severe inflammation. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. lower respiratory systeM infections Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. It becomes swollen and filled with blood. with a grayish membrane that wipes off readily. involving long-term antimicrobial therapy. whitish. Scarlet fever. Nonbacterial agents such as chlorine gas. is associated with a high rate of death in infants and the elderly. in order to prevent potentially disabling damage to lung tissue. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. and trench mouth may also produce acute tonsillitis. tuberculous. diphtheria.
leaving ulcers on the surface. and diseased skin cells to attach to and infiltrate the surface mucous membrane. Tracheitis Tracheitis is an inflammation and infection of the trachea. or overuse of the vocal cords. alcoholism. fibrin (blood clotting protein). the larynx can become obstructed. Most conditions that affect the trachea are bacterial or 96 . tissue destruction is followed by healing and scar formation. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. shorten the vocal cords. A similar type of membrane covering can occur in streptococcal infections. As the disease advances to the third stage. and produce a permanent hoarseness of the voice. they may consolidate at the vocal cords and cause an obstruction there. Tubercular nodule-like growths are formed in the larynx tissue. sores or mucous patches can form. The wall of the larynx may thicken and become inflamed. which closes the larynx during swallowing. It may cause a membrane of white blood cells. small lumps of tissue that project from the surface. The scars can distort the larynx. The bacteria die after infecting the tissue. When the epiglottis. Syphilitic laryngitis is one of the many complications of syphilis. Chronic laryngitis is produced by excessive smoking.7 The Respiratory System 7 inflammatory cells. There may be eventual destruction of the epiglottis and laryngeal cartilage. and suffocation may result. When looser portions of this false membrane become dislodged from part of the larynx. The mucous membrane becomes dry and covered with polyps. becomes swollen and infected by influenza viruses. In the second stage of syphilis. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx.
Irritants such as heavy smoking and alcoholism may invite infections. Diphtheria. streptococci. form in the mucous membrane. In smallpox. Chronic infections recur over a number of years and cause progressive degeneration of tissue. but the trachea may also be attacked. The infections produce fever. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. Diphtheria usually involves the upper mouth and throat. fatigue. Typhoid causes swelling and ulceration in the lymph tissue. they do not cause significant damage to the tissue unless they become chronic. and syphilis all afflict the trachea. Generally. Common bacterial causes of acute infections are pneumococci. and degeneration of the tracheal tissue can occur. The mucous glands may become swollen. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. and swelling of the mucous membrane lining the trachea. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. Intense blood congestion. Blood vessels increase in number. such as those that occur on the external skin. although irritants like chlorine gas. pustules and ulcers. and the walls thicken because of an increase in elastic and muscle fibres. Degenerated tissue is eventually replaced by a fibrous scar tissue.7 Infectious Diseases of the Respiratory System 7 viral infections. Infections may last for a week or two and then pass. Neisseria organisms. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. tuberculosis. Acute infections occur suddenly and usually subside quickly. and small polyplike formations occasionally grow. hemorrhages. The walls of the trachea during chronic infection contain an excess of white blood cells. and staphylococci. sulfur dioxide. smallpox. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. Syphilis forms lesions that erode the 97 .
the most frequent being those with the parainfluenza and influenza viruses. with high fever and breathing difficulties. and difficult breathing. Some cases result from allergy or physical irritation of these tissues. It is characterized by marked swelling of the epiglottis. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. Bacterial croup. In cases of severe airway obstruction.7 The Respiratory System 7 tissue. inflammation occurs around the bronchial tree. Viral infections are the most common cause of croup. Such infections are most prevalent among children younger than age three. The onset is usually abrupt. the onset of viral croup is preceded by the symptoms of the common cold for several days. hoarseness. or inflammation around the trachea. there is obstruction at the opening of the trachea. The symptoms are caused by inflammation of the laryngeal membranes. hospitalization may be necessary. In some cases. also called epiglottitis. Croup Croup is an acute respiratory illness of young children that is characterized by a harsh cough. making it necessary for the patient to sit and lean 98 . Generally. and can cause thickening and stiffening of the spaces between the cartilage. It is most often caused by an infection of the airway in the region of the larynx and trachea. is a more serious condition that is often caused by Haemophilus influenzae type B. Epinephrine and corticosteroids have also been used to reduce swelling of the airway. and they strike most frequently in late fall and winter. Because of the marked swelling of the epiglottis. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. spasms of the laryngeal muscles.
Patients are given antibiotics. Acute bronchitis can also be caused by bacteria such as Streptococcus. whooping cough. ammonia. and measles. Under ordinary circumstances. It is most frequently caused by viruses responsible for upper respiratory infections. organisms do enter the airways and initiate a sudden and rapid attack. Children with epiglottitis require prompt medical attention. the sensitive mucous membranes lining the inner surfaces of the bronchi are well protected from inhaled infectious organisms by the filtering function of the nose and throat and by the cough reflex. An artificial airway must be opened. Therefore. through which air passes into the lungs. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. however. it is often part of the common cold and is a common sequel to influenza. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. resulting usually in a relatively brief disease called acute infectious bronchitis. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. Epiglottitis generally strikes children between ages three and seven. or organic solvents.7 Infectious Diseases of the Respiratory System 7 forward to maximize the airflow. Infectious Bronchitis Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. In addition. particularly in people who have underlying chronic lung disease. influenzae. Under certain circumstances. preferably by inserting a tube down the windpipe. which generally relieve the inflammation within 24 to 72 hours. 99 .
In isolated cases. particularly in children between ages one and two. called chronic bronchitis. but it normally clears spontaneously. acute exacerbations of infection are associated with further damage to small airways. and particularly in infections with respiratory syncytial virus. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. in whom such a syndrome may follow the acute exposure. In adults. bronchodilators. and expectorants will usually relieve the symptoms. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability. is a long-standing. In some cases the inflammation may be severe enough to threaten life. though there is little doubt that in most patients with chronic bronchitis. repetitive condition. Another form of bronchitis. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. or this may develop slowly over time. 100 . Bronchiolitis probably occurs to some extent in acute viral disorders. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal. which results in protracted and often permanent damage to the bronchial mucosa. In addition to patients acutely exposed to gases. Steam inhalation. with complete healing in all but a very small percentage of cases. Bronchiolitis Bronchiolitis refers to inflammation of the small airways.7 The Respiratory System 7 Treatment of acute bronchitis is largely symptomatic and of limited benefit. This pattern of occurrence has only recently been recognized. an acute bronchiolitis episode is followed by a chronic obliterative condition. discussed in a later chapter.
Symptomatic recovery may mask incomplete resolution of the inflammation. and the lesion is an acute bronchiolitis. These develop some hours later. when welding in enclosed spaces such as boilers.7 Infectious Diseases of the Respiratory System 7 Welding in enclosed spaces often results in exposure to oxides of nitrogen. but a short cough and progressive shortness of breath may not be evident for hours. Monty Rakusen/Cultura/Getty Images Exposure to oxides of nitrogen. known as a respiratory bronchiolitis. A chest radiograph shows patchy inflammatory change. is believed to be the earliest change that occurs in the lung in cigarette smokers. after blasting underground. when the victim develops a short cough and progressive shortness of breath. or in fires involving plastic materials. which may occur from inhaling gas in silos. An inflammation around the small airways. 101 . is characteristically not followed by acute symptoms.
often accompanied by irritation or a sense of rawness in the throat. and the person begins to recover. and it is generally more frequent during the colder months of the year. together with varying degrees of soreness in the head and abdomen. though the highest incidence of the disease is among children and young adults. by such means as inhalation of infected droplets resulting from coughing and sneezing. is an acute viral infection of the upper or lower respiratory tract that is marked by fever. In three to four days the temperature begins to fall. fatigue. A diffuse headache and severe muscular aches throughout the body are experienced. and muscle aches. after which the onset of symptoms is abrupt.7 The Respiratory System 7 although it does not lead to symptoms of disease at that stage. It is not known whether those who develop this change (after possibly only a few years of smoking) are or are not at special risk of developing the long-term changes of chronic bronchitis and emphysema. The flu may affect individuals of all ages. also known simply as the flu (or grippe). The incubation period of the disease is one to two days. with sudden and distinct chills. and trachea. As the virus particles gain entrance to the body. chills. Symptoms associated with respiratory tract 102 . The inflammation is probably reversible if smoking is discontinued. and a generalized feeling of weakness and pain in the muscles. bronchial tubes. Influenza Influenza. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. The temperature rises rapidly to 38–40 °C (101–104 °F).
Other than this. become more prominent and may be accompanied by lingering feelings of weakness. In order to prevent humaninfecting bird flu viruses from mutating into more 103 . These viruses are produced in chick embryos and rendered noninfective. and yearly vaccination may be recommended. However. thereby reducing their effectiveness. and the use of analgesics to control fever. as treatment of viral infections with aspirin is associated with Reye syndrome. Protection from one vaccination seldom lasts more than a year.7 Infectious Diseases of the Respiratory System 7 infection. However. A newer category of drugs. Treatment and Prevention The antiviral drugs amantadine and rimantadine have beneficial effects on cases of influenza involving a strain of virus known as influenza type A. the neuraminidase inhibitors. viral resistance to these agents has been observed. usually among older people already weakened by other debilitating disorders. routine immunization in healthy people is also recommended. It is recommended that children and teenagers with the flu not be given aspirin. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. these drugs inhibit influenza A. such as coughing and nasal discharge. as well as a strain of virus known as influenza type B. was introduced in the late 1990s. a very serious illness. ingestion of fluids. the standard treatment remains bed rest. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). and is caused in most of those cases by complications such as pneumonia or bronchitis. Death may occur. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes.
Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. Zanamivir is given by inhalation only. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. Oseltamivir is marketed as Tamiflu by the U. If taken within 30 hours of 104 . Through the inhibition of neuraminidase. and decreases the spread of the virus through the body. Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses.7 The Respiratory System 7 dangerous subtypes. increases the formation of viral aggregates. known as H1N1.S. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. has developed resistance to oseltamivir. There is evidence that the most common subtype of influenza type A virus. The drug can also be used to prevent flu in adults and children who take the medication once daily for a period of at least 10 days. Oseltamivir can be given orally. Oseltamivir is effective when administered within two days of symptom onset.based pharmaceutical company Hoffman–La Roche. a glycoprotein on the surface of influenza viruses. increases the formation of viral aggregates. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors.S. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. Inc. and decreases the spread of the virus through the body. the drug decreases the release of virus from infected cells. zanamivir decreases the release of virus from infected cells.
highly communicable respiratory disease. when taken once daily for 10 to 28 days. Zanamivir.7 Infectious Diseases of the Respiratory System 7 the onset of influenza. zanamivir can shorten the duration of the illness. sticky mucus and often with vomiting. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. isolated and coloured with Gram stain. Bordetella pertussis. is an acute. Centers for Disease Control and Prevention (CDC) (Image Number: 2121) 105 . or “whoop. the causative agent of whooping cough. can prevent influenza infection in some adults and children. or pertussis.” The coughing ends with the expulsion of clear. Whooping Cough Whooping cough. Whooping cough is caused by the bacterium Bordatella pertussis.
undoubtedly it had existed for a long time before that. The infected person may appear blue. and be dazed and apathetic. and pertussis) vaccine. Complications of whooping cough include pneumonia. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. the illness progresses through three stages—catarrhal. The disease was first adequately described in 1578.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. with a short dry cough that is worse at night. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. Immunization is routinely begun at two months of age and requires five shots for maximum 106 . ear infections. Whooping cough is worldwide in distribution and among the most acute infections of children. and occasionally convulsions and indications of brain damage. paroxysmal. and a low-grade fever. tetanus. In the paroxysmal state. It was first called the Bordet-Gengou bacillus. Now included in the DPT (diphtheria. the name pertussis (Latin: “intensive cough”) was introduced in England. slowed or stopped breathing. During the convalescent stage there is gradual recovery. Beginning its onset after an incubation period of approximately one week. later Haemophilus pertussis. there is a repetitive series of coughs that are exhausting and often result in vomiting. About 100 years later. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. and still later Bordetella pertussis. but the periods between coughing paroxysms are comfortable. red eyes. In 1906 at the Pasteur Institute. Catarrhal symptoms are those of a cold. it confers active immunity against whooping cough to children. and convalescent—which together last six to eight weeks. variable in duration but commonly lasting four to six weeks. with bulging eyes.
the causative agent was revealed. Later vaccinations are in any case thought to be unnecessary. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. also known as ornithosis (or parrot fever). parrots and parakeets (family Psittacidae. when severe outbreaks. although a thorough study of the disease was not made until 1929– 30. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. Sedatives may be administered to induce rest and sleep. Strict regulations followed concerning 107 . ducks. especially if they have been vaccinated in infancy. The infection has been found in about 70 different species of birds. and another booster is given when the child is between four and six years old. and the United States. and sometimes the use of an oxygen tent is required to ease breathing. The association between the human disease and sick parrots was first recognized in Europe in 1879. from which the disease is named). Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. During the investigations conducted in Germany.7 Infectious Diseases of the Respiratory System 7 protection. because the disease is much less severe when it occurs in older children. and geese are the principal sources of human infection. Treatment includes erythromycin. turkeys. Psittacosis Psittacosis. attributed to contact with imported parrots. an antibiotic that may help to shorten the duration of illness and the period of communicability. England. pigeons. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. occurred in 12 countries of Europe and America.
viruses more commonly play a part in weakening the lung. Many organisms. or irradiation. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. ducks. but the most common causes are bacteria. have reduced resistance to 108 . weakness. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. Psittacosis usually causes only mild symptoms of illness in birds. Fungal pneumonia can develop very rapidly and may be fatal. Other symptoms include chills. in particular species of Streptococcus and Mycoplasma. can cause pneumonia. and an elevated respiratory rate. inhalation of foreign particles. but penicillin and the tetracycline drugs reduced this figure almost to zero. the case fatality rate was approximately 20 percent. including viruses and fungi. or geese have caused many cases among poultry handlers or workers in processing plants. Before modern antibiotic drugs were available. Infected turkeys. The typical duration of the disease is two to three weeks. Pneumonia Pneumonia is an inflammation and solidification of the lung tissue as a result of infection. and convalescence often is protracted. head and body aches.7 The Respiratory System 7 importation of psittacine birds. but it usually occurs in hospitalized persons who. because of impaired immunity. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. Although viral pneumonia does occur. thus inviting secondary pneumonia caused by bacteria. In humans psittacosis may cause high fever and pneumonia. but in humans it can be fatal if untreated.
cough. caused by Streptococcus pneumoniae. Bacterial Pneumonia Streptococcal pneumonia. smoke inhalation). and difficulty in breathing. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the 109 . Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. is the single most common form of pneumonia. Pneumonia can also occur as a hypersensitivity.7 Infectious Diseases of the Respiratory System 7 infection. coughing becomes the major symptom. to agents such as mold. when inhaled by previously healthy individuals. humidifiers. or allergic response. can sometimes cause fungal lung diseases. chest pain. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. Treatment is with specific antibiotics and supportive care. the illness may become very severe.g. Sputum discharge may contain flecks of blood. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. and animal excreta or to chemical or physical injury (e.. especially in hospitalized patients. In some cases. The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing. particularly in elderly people and young children. and it is sometimes fatal. however. As the disease progresses. and recovery generally occurs in a few weeks. Contaminated dusts. These fluids provide an environment in which the bacteria flourish.
Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. caused by Mycoplasma pneumoniae. M. Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. Other bacterial pneumonias include Legionnaire disease. Most outbreaks of this disease are confined to families. and influenza viruses. although epidemics can occur. Klebsiella pneumoniae. Usually the organism does not invade the membrane that surrounds the lungs. although it has little ability to infect the lungs of healthy persons. Research into the development of aerosol agents that stimulate blood clotting and that can be inhaled into the lungs and possibly be used in conjunction with traditional therapies for streptococcal pneumonia is ongoing. elastic fibres. but it does sometimes inflame the bronchi and alveoli. parainfluenza. causing bleeding into the air spaces. caused by Legionella pneumophilia. it does not invade the deeper tissues—muscle fibres. and psittacosis. or institutions.7 The Respiratory System 7 lungs. which leads to the further release of pneumolysin. small neighbourhoods. usually affects children and young adults. Another bacterium. few cases beyond age 50 are seen. Mycoplasmal pneumonia. an atypical infectious form. Symptoms of 110 . pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. an extremely small organism. or nerves. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures.
these patients experience fever with chills. Initially. AIDS. and doves may develop manifestations of hypersensitivity pneumonia. gerbils. These pneumonias may occur following exposure to moldy hay or sugarcane. parakeets. pigeons. decreased appetite. old sheds or barns. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. particularly if the patient was recently exposed to excavations. and malaise. or dust storms. and wood pulp may cause similar illnesses. Nonbacterial pneumonia is treated primarily with supportive care. and low-grade fever. the prognosis is excellent. usually followed by respiratory congestion and cough. shortness of breath. Diagnosis is established by physical examination and chest X-rays. and air-conditioning ducts. room humidifiers. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. muscle pain. A more insidious form of hypersensitivity pneumonia is 111 . Other fungi found in barley. headache. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. backyard swimming pools. maple logs. Tuberculosis should always be considered a possibility in any patient with pneumonia. In general. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. all of which may subside in a day if there is no further exposure. In addition. and skin testing is included in the initial examination of patients with lung problems. all of which contain the fungus Actinomyces. people exposed to rats. or other chronic diseases. cough.7 Infectious Diseases of the Respiratory System 7 these pneumonias include runny nose.
it had been known that if the immune system was compromised by immunosuppressive drugs (given. are difficult to treat. Scar tissue forms as a result of the presence of the oil. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. Pneumonia in Immunocompromised Persons For some years prior to 1980. it may come from the body itself when the lung is physically injured. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. for example. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. before organ transplantation to reduce the rate of rejection). weight loss. This type of disease. fever.) Recovery is usual unless too great an area of lung tissue is involved. or. and specific laboratory tests. Treatment consists of removing the patient from the offending environment. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. bed rest. Oil that is being swallowed may be breathed into the respiratory tract. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. physical examination. and supportive care. capable of causing invasive pneumonic lesions in the setting of reduced immunity. Ordinarily no treatment is necessary.7 The Respiratory System 7 associated with persistent malaise. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. and may prove fatal. Infections with fungi such as 112 . Such infections are a major cause of illness in these patients. and cough. known as lipoid pneumonia. less often. Diagnosis is established by medical history.
Although it is fairly well documented that the disease is rarely spread through person-to-person contact.7 Infectious Diseases of the Respiratory System 7 Candida also occur. pleurisy-like pain. the exact source of outbreaks is often difficult to determine. 113 . Although healthy individuals can contract Legionnaire disease. and occasionally some mental confusion is present. a U. 29 of them fatally. Coughing.S. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. pneumophila in droplets into the surrounding atmosphere. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. followed by high fever. as is water at construction sites. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. often accompanied by chills. the first symptoms of Legionnaire disease are general malaise and headache. at a Philadelphia hotel where 182 Legionnaires contracted the disease. Legionnaire Disease Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. shortness of breath. Potable water and drainage systems are suspect. Typically. occurred in Murcia. Spain. military veterans’ organization. in 2001. confirmed in more than 300 people. and abdominal distress are common. but not uniformly. The diagnosis and management of these cases has become a challenging and time-consuming responsibility for respiratory specialists in locations with large numbers of AIDS cases. The largest known outbreak of Legionnaire disease.
and death. Treatment for Legionnaire disease is with antibiotics. In most forms of the disease. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication. this cycle of infection can lead to severe pneumonia. at which time improved health and hygiene brought about a steady decline in its mortality rates. Tuberculosis Tuberculosis is an infectious disease that is caused by the tubercle bacillus. However. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. coma. During the 18th and 19th centuries. “consumption. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L.7 The Respiratory System 7 Once in the body. represents a milder form of Legionella infection. the bacillus spreads slowly and widely in the lungs. an influenza-like illness characterized by fever. and muscle pain. Blood vessels also can be eroded by the advancing disease. causing the infected person to cough up bright red blood. Since the 114 . L. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. headache. In some cases. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis.” as it was then known. the macrophage dies and bursts open. Mycobacterium tuberculosis. Indeed. pneumophila enters the lungs. Eventually. L. Pontiac fever. pneumophila. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America.
the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 .7 Infectious Diseases of the Respiratory System 7 Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries. it continues to be a fatal disease continually complicated by drug-resistant strains. in less-developed countries where population is dense and hygienic standards poor. Today. and drug therapy has done away with the old TB sanatoriums where patients at one time were nursed for years while the defensive properties of their bodies dealt with the disease. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. tuberculosis remains a major fatal disease. antibiotic drugs have reduced the span of treatment to months instead of years. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. but in areas with poor hygiene standards. Fox Photos/Hulton Archive/Getty Images 1940s. In addition.
There the bacilli become trapped in the tissues of the body. cheeselike (caseous) in appearance. In this condition. nodular tubercles. sometimes involving the use of five different agents. but most of the visible manifestations of tuberculosis. In otherwise healthy children and adults. A skin test taken at any later time may reveal the earlier infection and the immunity. and the infected person acquires a lifelong immunity to the disease. are surrounded by immune cells. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. The bacilli are quickly sequestered in the tissues. Infections with these strains are often difficult to treat and require the use of combination drug therapies. Minute droplets ejected by sneezing. A tubercle usually consists of a centre of dead cells and tissues. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. the primary infection often heals without causing symptoms. and finally are sealed up in hard. Individual tubercles are microscopic in size. and a small scar in the lung may be visible by X-ray. sometimes called latent 116 . from barely visible nodules to large tuberculous masses. The Course of Tuberculosis The tubercle bacillus is a small. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. rod-shaped bacterium that is extremely hardy. are conglomerations of tubercles. coughing. in which can be found many bacilli. it can survive for months in a state of dryness and can also resist the action of mild disinfectants.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics.
a highly fatal form if not adequately treated. the affected person is not contagious. though most affected people now recover. and there may be blood in the sputum. with lack of energy. or collection of fluid outside the lung. causing a pleural effusion. Tubercular lesions 117 . skin. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. intestines. the patient may have chest pain from pleurisy. they can travel to almost any organ of the body. In some cases the infection may break into the pleural space between the lung and the chest wall. These symptoms do not subside. however. and the general health of the patient deteriorates. In some cases. including the lymph nodes. The onset of pulmonary tuberculosis is usually insidious. weight loss. This causes a condition known as pulmonary tuberculosis. Eventually. Fever develops. the original tubercles break down. An infection of the meninges that cover the brain causes tuberculous meningitis. causing miliary tuberculosis. causing the patient to cough up blood (hemoptysis). usually with drenching night sweats. the primary infection may spread through the body. once the bacilli enter the bloodstream. and bladder. In fact. This lesion may erode a neighbouring bronchus or blood vessel. From the blood the bacilli create new tissue infections elsewhere in the body. for example). genital organs.7 Infectious Diseases of the Respiratory System 7 tuberculosis. before the advent of specific drugs. a highly infectious stage of the disease. In the lung. kidneys. this disease was always fatal. bones and joints. an alarming symptom. releasing viable bacilli into the bloodstream. and persistent cough. Particularly among infants. sometimes after periods of time that can reach 40 years or more. and immunocompromised adults (organ transplant recipients or AIDS patients. the elderly. most commonly in the upper portion of one or both lungs. the cough increases.
is characterized by softening and collapse of the vertebrae. aviumintracellulare). The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. and mycobacteria other than tuberculosis (MOTT). M. and this. It shows. ulcerans. finally eroding through the skin as a chronic discharging ulcer. causing large areas of destruction. 118 . M. marinum. and M. bovis readily infects humans. has led to the disappearance of bovine tuberculosis in humans in many countries. If the milk is ingested raw. and scarring. and it is also excreted in milk. Tuberculosis of the spine. bovis. M. kansasii. or Pott disease. bovis is transmitted among cattle and some wild animals through the respiratory route. atypical mycobacteria. cavities. however. avium (or M. The node swells under the skin of the neck. M. The amount of lung tissue available for the exchange of gases in respiration decreases. a great preference for bones and joints. Pasteurization of milk kills tubercle bacilli.7 The Respiratory System 7 may spread extensively in the lung. From the gastrointestinal tract. is the cause of bovine tuberculosis. along with the systematic identification and destruction of infected cattle. often resulting in a hunchback deformity. where it causes caseation of the node tissue (a condition formerly known as scrofula). where it causes destruction of tissue and eventually gross deformity. bovis may spread into the bloodstream and reach any part of the body. Other Mycobacterial Infections Another species of bacteria. M. M. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. This group includes such Mycobacterium species as M. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion.
however. Treatment is attempted with various drugs. it causes a local reaction. The primary method used to confirm the presence of bacilli is a sputum smear. The main hope of ultimate control. its use in young children in particular has helped to control infection in the developing world. A vaccine. individuals at risk 119 . stained with a compound that penetrates the organism’s cell wall. lies in preventing exposure to infection. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. which confers some immunity to infection by M. in gastric washings. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. tuberculosis. is composed of specially weakened tubercle bacilli. but the prognosis is usually poor owing to the AIDS patient’s overall condition. atypical mycobacterial illnesses are common complications of HIV infection. and other organs only in people whose immune systems have been weakened.7 Infectious Diseases of the Respiratory System 7 These bacilli have long been known to infect animals and humans. Injected into the skin. and examined under a microscope. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. or in the cerebrospinal fluid. possibly in isolation until they are noninfectious. known as BCG vaccine. If bacilli are present. but they cause dangerous illnesses of the lungs. in the urine. It has been widely used in some countries with success. Among AIDS patients. lymph nodes. In many developed countries. and this means treating infectious patients quickly. in which a sputum specimen is smeared onto a slide. An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. tuberculosis for several years.
in order to avoid the development of drug-resistant bacilli. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). Today. ethambutol. of bed rest and surgical removal of useless lung tissue. These drugs are often used in various combinations with other agents. or rifapentine. often years. If a patient does not continue treatment for the required time or is treated with only one drug. pyrazinamide. Historically. As a result. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. If subsequent treatment is also incomplete. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. such as health care workers. 120 . the surviving bacilli will become resistant to several drugs. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. These drugs may be given daily or two times per week. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid.7 The Respiratory System 7 for tuberculosis. surgery is rarely needed. such as ethambutol. with early drug treatment. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. and pyrazinamide. The length of the continuous treatment period depends on the results of chest X-rays and sputum smears taken at the end of the two-month period of initial therapy. rifampicin. treatment of tuberculosis consisted of long periods. bacilli will become resistant and multiply. but complete cure requires continuous treatment for another four to nine months. The patient is usually made noninfectious quite quickly. making the patient sick again.
MDR TB is treatable but is extremely difficult to cure.7 Infectious Diseases of the Respiratory System 7 Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. it has proved successful in controlling tuberculosis. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. amikacin. 121 . Instead of taking daily medication on their own. Although some patients consider DOT invasive. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. such as kanamycin. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. XDR TB is characterized by resistance to not only isoniazid and rifampin but also a group of bactericidal drugs known as fluoroquinolones and at least one aminoglycoside antibiotic. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). or capreomycin. In addition. in part to prevent the development and spread of MDR TB. In 1995. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. Aggressive treatment using five different drugs.
bronchial tree. ranging from inherited genetic mutations to smoking to trauma. emphysema. Thus. The causes of the various diseases and disorders are diverse. sinuses. there are diseases of the upper airways. diseases of the larynx. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. and disease in one region frequently leads to involvement of other parts. T diseases of the upper airway The nose. and nasopharynx are all susceptible to disease. Treatment for this group of conditions is similarly varied. they are by no means rigid. and lungs. and cystic fibrosis.CHAPTER5 DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. palate. Conditions affecting these tissues may 122 . and diseases of the mediastinum and diaphragm. trachea. Important examples of diseases and disorders of the respiratory system include sleep apnea. diseases of the pleura. and in many cases therapy may include not only the administration of medications but invasive surgery as well. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect. Although these divisions provide a general outline of the ways in which diseases may affect the lung. It is common for more than one part of the system to be involved in any particular disease process.
Snoring is more common in the elderly because the loss of tone in the oropharyngeal Although snoring bears the brunt of many jokes. loud interrupted snoring can indicate sleep apnea. Snoring Snoring is a rough. It is often associated with obstruction of the nasal passages. Such cancers are typically more common in smokers than in nonsmokers.. which necessitates breathing through the mouth. cancer). a potentially life-threatening condition. © www .istockphoto.com / Stephanie Horrocks 123 .7 Diseases and Disorders of the Respiratory System 7 result from a number of different causes. such as congenital structural abnormalities or malignant neoplastic changes (i.e. hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords.
Whatever the cause. The word apnea is derived from the Greek apnoia. meaning “without breath. a common and potentially lifethreatening condition that generally requires treatment. In addition. snoring is always associated with mouth breathing and can be corrected by removing obstructions to normal nasal breathing or by altering sleeping position so that the affected individual does not lie on his back. which is the most common form and involves the collapse of tissues of the upper airway. airway collapse is eventually terminated by a brief awakening. which involves characteristics of both obstructive and central apneas. Children’s snoring usually results from enlarged tonsils or adenoids. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. body weight. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. Loud interrupted snoring is a regular feature of sleep apnea. the condition has a strong association with certain measures of obesity. or body-mass index. Obstructive sleep apnea is most often caused by excessive fat in the neck area. Thus. It is also more common in men than in women. In obstructive sleep apnea (OSA). and mixed. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx.” There are three types of sleep apnea: obstructive. In men shirt size is a useful predictor. central. with the likelihood of OSA increasing 124 . and it occurs most often in obese persons. such as neck size. at which point the airway reopens and the person resumes breathing.
and increase irritability. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. Sleep disturbance may cause difficulty concentrating.5 inches). The most common symptom of OSA is sleepiness. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. Other causes of the condition include medical disorders. it is less certain that these diseases are caused by OSA. with many patients describing sleep as unrefreshing. worsen short-term memory. However.7 Diseases and Disorders of the Respiratory System 7 with a collar greater than about 42 cm (16. it does prevent airway collapse and thus relieves daytime sleepiness. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. such as hypothyroidism or tonsillar enlargement. The risk returns to normal after treatment. Treatment typically involves continuous positive airway pressure (CPAP). hypertension.and sevenfold. which can be resolved only by weight loss or treatment of underlying conditions. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. Although CPAP does not treat the condition itself. though surgery is seldom recommended. the magnitude of the increased risk is the subject of some debate but is thought to be between three. 125 . Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. and insulin resistance. which uses a mask (facial or nasal) during sleep to blow air into the upper airway. including ischemic heart disease. The condition is also more common in patients with a set-back chin (retrognathia). with the resumption of breathing usually described as a gasp or a snort. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents.
7 The Respiratory System 7 Pickwickian Syndrome Pickwickian syndrome. In more severe instances. excessive fluid accumulates throughout the body (peripheral edema). The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. drowsiness. Individuals who have pickwickian syndrome often complain of slow thinking. The elevated pressure stresses the right ventricle of the heart. levels of carbon dioxide in the blood increase. Because of inadequate removal of carbon dioxide by the lungs. is a complex of respiratory and circulatory symptoms associated with extreme obesity. also known as obesity hypoventilation syndrome. leading to respiratory acidosis. to be obese is to exceed one’s ideal weight by 20 percent or more.) This condition often occurs in association with sleep apnea. and fatigue. ultimately causing right heart failure. (By some definitions. especially beneath the skin of the lower legs. oxygen in the blood is also significantly reduced. Finally. who showed some of the same traits. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level. Low blood oxygen causes the small blood vessels entering the lungs to constrict. The pleural membranes of the 126 . an extremely obese person would exceed the optimum weight by a much larger percentage. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers. diseases of the pleura The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. in the space known as the pleural cavity. thus increasing pressure in the vessels that supply the lungs.
rarely. Pleurisy is commonly caused by infection in the underlying lung and. a partial or occasionally complete collapse of the lung. by diffuse inflammatory conditions such as lupus erythematosus. little or no abnormal fluid accumulates in the pleural cavity.7 Diseases and Disorders of the Respiratory System 7 lungs are also vulnerable to perforation and spontaneous rupture. This causes spontaneous pneumothorax. enabling air to enter the pleural cavity. Treatment of pleurisy includes pain relief. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. is an inflammation of the pleura. In dry pleurisy. the membranes that line the thoracic cavity and fold in to cover the lungs. Pleurisy may be characterized as dry or wet. Mesothelioma. and treatment of the underlying disease. or hydrothorax. is an accumulation of watery fluid in the pleural cavity. Pleural Effusion and Thoracic Empyema Pleural effusion. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. pleurisy can be very painful. In wet pleurisy. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. Because the pleura is well supplied with nerves. a cancer of the pleura. fluid evacuation. fluids produced by the inflamed tissues accumulate within the pleural cavity. There are many causes of 127 . may occur many years after inhalation of asbestos fibres. Pleurisy Pleurisy. also called pleuritis. including tissues of the neck and head.
such as malignant disease of the pleura (i. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. and the presence of fluid as ascertained by a chest X-ray. and weight loss.e. and the spread of a malignant tumour from a distant site to the pleural surface. Thoracic empyema may be characterized by fever. coughing. doxycycline. Treatment is directed at drainage of small amounts of pus through 128 . shortness of breath. and fluid that seeps from the lungs places additional stress on the dysfunctioning heart. If symptoms of pleural effusion develop. As the inflammation heals. When the bronchial tree is involved in the infection. Large pleural effusions can cause disabling shortness of breath. The accumulation of pus in the pleural cavity is known as thoracic empyema.7 The Respiratory System 7 pleural effusion. This condition is often the result of a microbial. tuberculosis. thereby preventing the accumulation of more fluid. usually bacterial. It may also be caused by a lung abscess or some forms of tuberculosis. infection within the pleural cavity. a tube is inserted through the chest wall into the pleural space to drain the fluid. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. tissue adhesions obliterate the pleural space. Under certain conditions. including pneumonia.. mesothelioma). or pyothorax. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. air may get into the pleural cavity. and bleomycin. pleural effusion can be treated by introducing an irritating substance called a sclerosing agent into the pleural space in order to stimulate an inflammatory reaction of the pleural surfaces. The presence of both air and pus inside the pleural cavity is known as pneumothorax.
Antibiotics are used to treat the underlying infection. chest compression during cardiopulmonary resuscitation (CPR). spontaneous pneumothorax. and tension pneumothorax. such as high-pressure mechanical ventilation. lung infection. As a result. which may then collapse. with each breath the patient inhales. Spontaneous pneumothorax is the passage of air into the pleural sac from an abnormal connection created between the pleura and the bronchial system as a result of bullous emphysema or some other lung disease.7 Diseases and Disorders of the Respiratory System 7 a needle or larger amounts through a drainage tube. or medical procedures. When the lung on the affected side of the chest collapses. Pneumothorax Pneumothorax is a condition in which air accumulates in the pleural space. air and pressure accumulate within the chest. or thoracoscopy (closed-lung biopsy). after which air is sucked through the opening and into the pleural sac. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. blood 129 . In contrast to traumatic pneumothorax and spontaneous pneumothorax. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. in tension pneumothorax air that becomes trapped in the pleural space cannot escape. the heart. There are three major types of pneumothorax: traumatic pneumothorax. causing it to expand and thus compress the underlying lung. gunshot) or other injuries to the chest wall.
many of these conditions are associated with irreversible lung damage. It consists of a dilatation of major bronchi. In fact. others may require surgery to prevent recurrences. consciousness. and breathing that in turn may lead to shock and death. This leads to decreases in blood pressure.7 The Respiratory System 7 vessels. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. occasionally. which enables the lung to reexpand. diseases of the bronchi and lungs Diseases of the bronchi and lungs are often associated with significant impairments in respiration. thereby compressing the other lung. Bronchiectasis Bronchiectasis is believed to usually begin in childhood. clubbing (swelling of the fingertips and. including bronchiectasis and cystic fibrosis. The disease may also develop as a consequence of airway obstruction or of undetected (and 130 . While small pneumothoraxes may resolve spontaneously. possibly after a severe attack of pneumonia. In some cases. a catheter connected to a vacuum system is required to re-expand the lung. of the toes) may occur. Whereas several diseases of the bronchi and lungs. The bronchi become chronically infected. This procedure allows air to escape from the chest cavity. may be present in childhood. In some cases. and excess sputum production and episodes of chest infection are common. Most pneumothoraxes can be treated by inserting a tube through the chest wall. and airways are pushed to the centre of the chest.
now reach adult life. But the striking increase in mortality from chronic bronchitis and emphysema that occurred after World War II in all Western countries indicated that the long-term consequences of chronic bronchitis could be serious. Chronic Bronchitis The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough. of which the most important is the familial disease cystic fibrosis. particularly in areas of uncontrolled coal burning. Management of the condition includes antibiotics to fight lung infections. due to an increase in size and number of mucous glands lining the large airways.7 Diseases and Disorders of the Respiratory System 7 therefore untreated) aspiration into the airway of small foreign bodies. medications to dilate the airways and to relieve pain. many of whom. and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. such as parts of plastic toys. For example. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants. enzyme therapy to thin the mucus. who would formerly have died in childhood.” without serious implications. or of organic substances such as hay dust. In some countries chronic bronchitis is caused by daily 131 . These therapies. have helped control pulmonary infections and have markedly improved survival in affected persons. The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air. significant quantities of mucus are coughed up in the morning. After about 15 years of smoking. This common condition is characteristically produced by cigarette smoking. in addition to others. Bronchiectasis may also develop as a consequence of inherited conditions.
causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. whereas others may experience severe respiratory compromise after 15 years or less of exposure. the ventilatory ability of the patient. in a cigarette smoker. Occasionally. can lead to disturbances in the distribution of ventilation and perfusion in the lung.7 The Respiratory System 7 inhalation of wood smoke from improperly ventilated cooking stoves. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. if severe enough. For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. is severely compromised. All these changes together. though these produce the dominant symptom of chronic sputum production. Smoking-related chronic bronchitis often occurs in association with emphysema. The changes are not confined to large airways. By the time this occurs. though the rate of progression generally slows. Of primary importance is 132 . Because the damage to the bronchial tree is largely irreversible. but they must be used sparingly because they can be addictive and because expectoration is necessary. Some people can smoke for decades without evidence of significant airway changes. It is not clear what determines the severity of these changes. treatment is mainly symptomatic. drugs to suppress paroxysmal coughing may be necessary. ventilatory ability has usually been declining rapidly for some years. Unfortunately. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. The mucus-producing cough will subside within weeks or months and may resolve altogether. as measured by the velocity of a single forced expiration. consisting of expectorants and bronchodilators. the coexistence of these two conditions is known as chronic obstructive pulmonary disease.
7 Diseases and Disorders of the Respiratory System
the prevention of superimposed infections, either by careful watching for early signs or by using prophylactic antibiotics. Adjusting the patient’s living and working environments to the largely irreversible condition is an essential factor in treatment.
This irreversible disease consists of destruction of alveolar walls. It occurs in two forms, centrilobular emphysema, in which the destruction begins at the centre of the lobule, and panlobular (or panacinar) emphysema, in which alveolar destruction occurs in all alveoli within the lobule simultaneously. In advanced cases of either type, this distinction can be difficult to make. Centrilobular emphysema is the form most commonly seen in cigarette smokers, and some observers believe it is confined to smokers. It is more common in the upper lobes of the lung (for unknown reasons). By the time the disease has developed, some impairment of ventilatory ability has probably occurred. Panacinar emphysema may also occur in smokers, but it is the type of emphysema characteristically found in the lower lobes of patients with a deficiency in the antiproteolytic enzyme known as alpha-1 antitrypsin. Similar to centrilobular emphysema, panacinar emphysema causes ventilatory limitation and eventually blood gas changes. Other types of emphysema, of less importance than the two major varieties, may develop along the dividing walls of the lung (septal emphysema) or in association with scars from other lesions. A major step forward in understanding the development of emphysema followed the identification, in Sweden, of families with an inherited deficiency of alpha-1 antitrypsin, an enzyme essential for lung integrity. Members of affected families who smoked cigarettes
The Respiratory System
Emphysema destroys the walls of the alveoli of the lungs, resulting in a loss of surface area available for the exchange of oxygen and carbon dioxide during breathing. This produces symptoms of shortness of breath, coughing, and wheezing. In severe emphysema, difficulty in breathing leads to decreased oxygen intake, which causes headaches and symptoms of impaired mental ability. Encyclopædia Britannica, Inc.
commonly developed panacinar emphysema in the lower lobes, unassociated with chronic bronchitis but leading to ventilatory impairment and disability. Intense investigation of this major clue led to the “protease-antiprotease” theory of emphysema. It is postulated that cigarette smoking either increases the concentration of protease enzymes released in the lung (probably from white blood cells) or impairs the lung’s defenses against these enzymes or both. Although many details of the essential biochemical steps at the cellular level remain to be clarified, this represents a major step forward in understanding a disease whose
7 Diseases and Disorders of the Respiratory System
genesis was once ascribed to overinflation of the lung (like overdistending a bicycle tire). Chronic bronchitis and emphysema are distinct processes. Both may follow cigarette smoking, however, and they commonly occur together, so determination of the extent of each during life is not easy. In general, significant emphysema is more likely if ventilatory impairment is constant, gas transfer in the lung (usually measured with carbon monoxide) is reduced, and the lung volumes are abnormal. Development of high-resolution computerized tomography has greatly improved the accuracy of detection of emphysema. Some people with emphysema suffer severe incapacity before age 60. Thus, emphysema is not a disease of the elderly only. An accurate diagnosis can be made from pulmonary function tests, careful radiological examination, and a detailed history. The physical examination of the chest reveals evidence of airflow obstruction and overinflation of the lung, but the extent of lung destruction cannot be reliably gauged from these signs, and therefore laboratory tests are required. The prime symptom of emphysema, which is always accompanied by a loss of elasticity of the lung, is shortness of breath, initially on exercise only, and associated with loss of normal ventilatory ability and increased obstruction to expiratory airflow. The expiratory airflow from a maximum inspiration is measured by the “forced expiratory volume in one second,” or FEV1, and is a predictor of survival of emphysema. Chronic hypoxemia (lowered oxygen tension) often occurs in severe emphysema and leads to the development of increased blood pressure in the pulmonary circulation, which in turn leads to failure of the right ventricle of the heart. The symptoms and signs of right ventricular failure include swelling of the ankles (edema) and engorgement of the neck veins. These are portents of advanced lung disease in this condition. The
The Respiratory System
hypoxemia may also lead to an increase in total hemoglobin content and in the number of circulating red blood cells, as well as to psychological depression, irritability, loss of appetite, and loss of weight. Thus, the advanced syndrome of chronic obstructive lung disease may cause such shortness of breath that the afflicted person has difficulty walking, talking, and dressing, as well as numerous other symptoms. The slight fall in ventilation that normally accompanies sleep may exacerbate the failure of lung function in chronic obstructive lung disease, leading to a further fall in arterial oxygen tension and an increase in pulmonary arterial pressure. Unusual forms of emphysema also occur. In one form the disease appears to be unilateral, involving one lung only and causing few symptoms. Unilateral emphysema is believed to result from a severe bronchiolitis in childhood that prevented normal maturation of the lung on that side. “Congenital lobar emphysema” of infants is usually a misnomer, since there is no alveolar destruction. It is most commonly caused by overinflation of a lung lobe due to developmental malformation of cartilage in the wall of the major bronchus. Such lobes may have to be surgically removed to relieve the condition. Bullous emphysema can occur in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung tissue. This disease most commonly occurs between ages 15 and 30 and usually is not recognized until a bullous air space leaks into the pleural space, causing a pneumothorax.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by the
It is a common disease. Sources of noxious particles that can cause COPD include tobacco smoke.000 people in the United States die from COPD.000 people in the United Kingdom and roughly 119. COPD is distinguished pathologically by the destruction of lung tissue. and the burning of certain fuels in poorly ventilated areas. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). which is replaced by holes characteristic of emphysema. antibiotics. either bacterial or viral. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. including muscle weakness and osteoporosis. air pollution. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. are not always required. Coughing up blood is not a feature of COPD and when present raises concern about a second. and each year about 30. and by a tendency for excessive mucus production in the airway. particularly lung cancer. which gives rise to symptoms of bronchitis. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. which work against bacteria. which causes increased lung volume and manifests as breathlessness. particularly if severe enough to warrant hospital admission. indicate a poor prognosis. Therefore. it is increasingly recognized that COPD has secondary associations. which 137 .7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. Exacerbations are triggered by infection. tobacco-related condition. Frequent exacerbations. Although primarily a lung disease.
Lung Congestion Lung congestion is characterized by distention of blood vessels in the lungs and filling of the alveoli with blood as a result of an infection.e. inability of the heart to function adequately).. bronchodilators). or cardiac insufficiencies (i. high blood pressure.. Some COPD patients do not find oxygen attractive.e. which leads to further difficulties in mobility. Inhaled corticosteroids are commonly prescribed. lung transplantation and lung-volume reduction). including noninvasive ventilation and surgical options (i. especially for patients with frequent exacerbations. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. Active congestion of the lungs is caused by 138 . Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i. In addition.. Specialized centres can offer treatments for patients with advanced disease. In COPD patients with low blood–oxygen levels. since they need to use it for 16 hours each day to derive benefit. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. This should be followed by a community/home maintenance program or by repeat courses every two years. A six.7 The Respiratory System 7 can be accomplished in most cases by cessation of smoking. oxygen is extremely flammable. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD.to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy.e.
Mitral stenosis. there is a bloody discharge. Left-sided heart failure—inability of the left side of the heart to pump sufficient blood into the general circulation—causes back pressure on the pulmonary vessels delivering oxygenated blood to the heart. flooding them. The walls of the alveoli also thicken and gas exchange is greatly impaired. Eventually the pressure becomes too great. and particles. Passive congestion is due either to high blood pressure in the capillaries.7 Diseases and Disorders of the Respiratory System 7 infective agents or irritating gases. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. The major complication arises in mild cases of pneumonia. when the remaining functioning tissue becomes infected. causes chronic passive congestion. and the precipitating causes may somewhat differ. In 139 . although there is usually enough unaffected lung tissue for respiration. The blood pressure becomes high in the alveolar capillaries. The alveolar walls and the capillaries in them become distended with blood. Inflammatory edema results from influenza or bacterial pneumonia. narrowing of the valve between the upper and lower chambers in the left side of the heart. and the skin takes on a bluish tint as the disease progresses. caused by a cardiac disorder. The affected person shows difficulty in breathing. liquids. and blood escapes through the capillary wall into the alveoli. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue. Blood accumulates in the lower part of the lungs. rather than whole blood. or to relaxation of the blood capillaries followed by blood seepage. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. and they begin to distend.
7 The Respiratory System 7 X-ray showing lung congestion caused by congestive heart failure. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6241) 140 . Dr.
The person’s skin turns blue. It can occur. either partially or fully. are not expanded with air. This is typically caused by a failure to develop surface-active material 141 . the person may actually drown in the lung secretions. after reinflation of a collapsed lung. Acute cases can be fatal in 10 to 20 minutes. A person with pulmonary edema experiences difficulty in breathing. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. After an operation. their lungs show areas in which the alveoli. The lungs become pale. compressive. The term atelectasis can also be used to describe the collapse of a previously inflated lung. The term is derived from the Greek words atele s and ektasis. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed.7 Diseases and Disorders of the Respiratory System 7 mechanical edema the capillary permeability is broken down by the same type of heart disorders and irritants as in congestion. There are three major types of atelectasis: adhesive. These infants usually suffer from a disorder called respiratory distress syndrome. for unknown reasons. It may take only one or two hours for two to three quarts of liquid to accumulate. and heavy. enlarged. if too great a volume of intravenous fluids is given. wet. Adhesive atelectasis is seen in premature infants who are unable to spontaneously breathe and in some infants after only a few days of developing breathing difficulties. the blood pressure rises and edema ensues. because of specific respiratory disorders. or air sacs. literally meaning “incomplete expansion” ¯ in reference to the lungs. Excessive irradiation and severe allergic reactions may also produce this disorder. with deep gurgling rattles in the throat. because he or she is too weak to clear the fluids. and. and obstructive.
7 The Respiratory System 7 X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis. Dr. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242) 142 .
7 Diseases and Disorders of the Respiratory System 7 (surfactant) in the lungs. It may also occur as a complication of abdominal surgery. which frequently enter with inhaled air. the respiratory tissue is replaced by fibrous scar tissue. soot. causing air trapped in the alveoli to be slowly absorbed by the blood. and the muscles beneath the lungs may be weakened. When a person undergoes surgery. Collapse is complete if the force is uniform or is partial when the force is localized. and bacterial cells. The air passageways in the lungs normally secrete a mucous substance to trap dust. If a lung remains collapsed for a long period. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. Other causes of obstruction include tumours or infection. Local pressure can result from tumour growths. which manifests as a bluish tint to the skin. and consolidation of the lungs into a smaller mass. absence of respiratory movement on the side involved. Mucous plugs can result that cause atelectasis. and respiratory function cannot be restored. The symptoms in extreme atelectasis include low blood oxygen content. displacement of the heart toward the affected side. they can be pushed out of the bronchi by coughing or strong exhalation of air. After abdominal surgery. Treatment for obstructive and compressive 143 . or elevation of the diaphragm. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. Generally. an enlarged heart. the anesthetic stimulates an increase in bronchial secretions. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements. Treatment for infants with this syndrome includes replacement therapy with surfactant. if these secretions become too abundant. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out.
however. The pain may be localized around the rib cage. or air bubbles in the bloodstream (both of these are instances of embolism). Pain is most severe on inhalation. The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. or it may be lower. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. when the lungs are healthy. 144 . lung infarctions can follow blockage of a blood vessel. The section of dead tissue is called an infarct. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac. infected. or the blockage may be by a clot that has formed in the blood vessel itself and has remained at the point where it was formed (such a clot is called a thrombus). and neck. shoulders. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest.7 The Respiratory System 7 atelectasis is directed toward removal of any obstruction or compressive forces. infarcts that occur deep inside the lungs produce no pain. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. near the muscular diaphragm that separates the chest cavity from the abdomen. When pain is present it indicates pleural involvement. Lung Infarction Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. If the lung is congested. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. Ordinarily. or inadequately supplied with air. such blockages fail to cause death of tissue because the blood finds its way by alternative routes.
The dead tissue is replaced by scar tissue. However.e.. The disease has no manifestations in heterozygotes (i. the chief symptom of which is the production of a thick. moderate difficulty in breathing. also known as mucoviscidosis. when both 145 . fever. It is much less common among people of African ancestry (about 1 per 17. by the mid-1980s. those individuals who have one normal copy and one defective copy of the particular gene involved).000 live births in these populations and is particularly concentrated in people of northwestern European descent. Cystic fibrosis was not recognized as a separate disease until 1938 and was then classified as a childhood disease because mortality among afflicted infants and children was high. diminished breath sounds.000 live births) and is very rare in people of Asian ancestry. The disorder was long known to be recessive (i.e. pleural rubbing. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. Infarcts that do not heal within two or three days generally take two to three weeks to heal. coughing. It is estimated to occur in 1 per 2. and a dull sound heard when the chest is tapped. Cystic Fibrosis Cystic fibrosis. is an inherited metabolic disorder. increased heartbeat. sticky mucus that clogs the respiratory tract and the gastrointestinal tract. However. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. only persons inheriting a defective gene from both parents will manifest the disease).. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells).
The thick. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. Bulky. one out of four of their offspring will have the disease. plugging the bronchi and making breathing difficult. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet. they may expect that. Most cases of cystic fibrosis are caused by a mutation that corresponds to the production of a CFTR protein that lacks the amino acid phenylalanine. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. and the progressive loss of lung function are the major manifestations of lung disease. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. lies in the middle of chromosome 7 and encodes a protein of the same name. designated CFTR. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. The gene. sticky mucus accumulates in the lungs. greasy. As a result. recurrent pneumonia. foul-smelling stools are often the first signs of cystic fibrosis. This results in chronic respiratory infections. or CFTR. In 1989 the defective gene responsible for cystic fibrosis was isolated. called cystic fibrosis transmembrane conductance regulator. often with Staphylococcus aureus or Pseudomonas aeruginosa.. Within the cells of the lungs and gut. Chronic cough. on the basis of chance. chloride and sodium ions accumulate within cells. the mucus-secreting and sweat glands) in the respiratory and digestive systems.7 The Respiratory System 7 parents are heterozygous. In the digestive system. which is the most common cause of death of persons with cystic fibrosis.g. About 10 146 . the CFTR protein transports chloride across cell membranes and regulates other channels.
bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. sometimes in aerosolized form. making it easier for patients to breathe. Many patients with cystic fibrosis regularly take antibiotics. and fat.7 Diseases and Disorders of the Respiratory System 7 percent of infants with cystic fibrosis have intestinal obstruction at birth due to very thick secretions. In severe cases. These tests are effective in the identification of adult carriers (heterozygotes). Medications such as dornase alfa. facilitating its clearance from the lungs through coughing. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. are given to thin mucus. as well as in the identification of newborns who may be at risk for the disorder. In addition. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. a recombinant form of the enzyme deoxyribonuclease.” which is the definitive diagnostic test for the presence of cystic fibrosis. 147 . The high salt content in perspiration is the basis for the “sweat test. lung transplantation may be considered. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. protein. These agents may be administered by means of an inhaler or a nebulizer. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. In addition. in order to fight lung infections. which is powered by a compressor that sprays aerosolized drug into the airways. Mutations associated with cystic fibrosis can be detected in screening tests. who may pass a mutation on to their offspring. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis.
the natural defense systems of the lungs and airways have proved significant obstacles to cellular uptake of the viral vector carrying the normal CFTR gene. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. cationic liposomes. the patients experienced severe side effects. The latter. These vectors were then transfected into the cultured cells. The same technology was used to insert the CFTR gene into a replication-deficient adenovirus that was then administered into the noses and lungs of patients.7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. Gene therapy first emerged as a potential form of treatment in 1990. including lung inflammation and signs of viral infection. Delivery systems under investigation include cationic polymer vectors. As a result. gene therapy for cystic fibrosis has undergone significant refinement. However. However. has proved particularly effective in laboratory studies using human lung tissue. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene. 148 . This first trial initially appeared to be successful. since increased expression of the CFTR protein was observed shortly after treatment. which subsequently incorporated the normal genes into their DNA. Since the 1990s. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. and the outcomes of clinical trials are marked by steady improvement. and adenovirus associated virus.
7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. In addition. called rales or “Velcro crackles. however. Other common changes are enlargement of the lymph 149 . Aside from administration of supplemental oxygen. The average duration of survival from diagnosis is four to six years. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. Sharp crackling sounds.” are heard through a stethoscope applied to the back in the area of the lungs. Some individuals may benefit from single or double lung transplantation. with insidious onset of shortness of breath on exertion. the lung is commonly involved. some people live 10 years or longer. there is no effective treatment. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. pulmonary function testing shows a reduction in lung volume. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. in different organs. Some individuals have clubbed fingertips and toes. or granulomas. The disease most commonly manifests between ages 50 and 70. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs. A dry cough is common as well.
the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. The disease usually remits without treatment within a year or so. or when the lung fails to remove the 150 . leading to signs of involvement in the affected area. also known as histiocytosis X. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. It causes lesions in lung tissue and sometimes also in bone tissue. Eosinophilic granuloma. Although its cause is unknown. Occasionally. Evidence of granulomas in the lung may be visible. minute structures in the lungs in which the exchange of respiratory gases occurs.7 The Respiratory System 7 glands at the root of the lung. The alveoli are air sacs. leading finally to lung fibrosis and respiratory failure. a subgroup of immune cells. skin changes. but often there is little interference with lung function. The kidney is not commonly involved. and liver dysfunction. Eosinophilic granuloma is a lung condition that may spontaneously “burn out. nerve sheaths are inflamed. but in a small proportion of cases it progresses. Pulmonary Alveolar Proteinosis Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. is a disease associated with the excess production of histiocytes. In most cases the disease is first detected on chest radiographs.” leaving the lung with some permanent cystic changes. When too much surfactant is released from the alveolar cells. The gas molecules must pass through a cellular wall. inflammation in the eye. the incidence is greatly increased in cigarette smokers. a complex mixture of protein and lipid (fat) molecules. but some changes in blood calcium levels occur in a small percentage of cases.
The disease can exist without causing symptoms for considerable periods. Immunologic Conditions of the Lung The lung is often affected by generalized diseases of the blood vessels.7 Diseases and Disorders of the Respiratory System 7 surfactant. is an important cause of pulmonary blood vessel inflammation. The fluids drawn back out of the lungs have been found to have a high content of fat. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. but its cause is not fully understood. The precipitating cause of the disease is unknown. X-rays most frequently show evidence of excess fluids in the lungs. an acute inflammatory disease of the blood vessels believed to be of immunologic origin. if treated. but subsequent treatments are often necessary. The condition has been successfully treated by exchange blood transfusion. but rarely so. Wegener granulomatosis. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. it is sometimes fatal. Treatment involves removal of the material by a rinsing out of the lungs (lavage). There may also be general fatigue and weight loss. Pulmonary hemorrhage also occurs as part of a condition 151 . The skin becomes tinged with blue in the most serious cases. and it is often accompanied by chest pain and a dry cough. One lung at a time is rinsed with a saltwater solution introduced through the windpipe. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. Sometimes the lesions totally clear up after one procedure. and spontaneous improvement has been known to occur. Persons affected are usually between ages 20 and 50.
The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. Pleural effusions may occur. lung cancer is the second leading cause of death from cancer globally. accurate diagnosis has been much improved by refinements in radiological methods. by the use of pulmonary function tests. The common condition of rheumatoid arthritis may be associated with scattered zones of interstitial fibrosis in the lung or with solitary isolated fibrotic lesions. a slowly obliterative disease of small airways (bronchiolitis) occurs. leading finally to respiratory failure. Lung cancer was first described by doctors in the mid-19th century. In the early 20th century it was considered relatively rare.3 million deaths each year. and the lung parenchyma may be involved. The rapid increase in the worldwide prevalence of lung cancer was attributed mostly to the increased use of cigarettes following World War I. lung cancer emerged as the leading cause of cancer deaths worldwide. In the 21st century. resulting in an estimated 1. In the United States. More rarely. which is also believed to have an immunologic basis. 152 . which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. it has surpassed breast cancer. following breast cancer. These conditions have only recently been recognized and differentiated. In women. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. however.7 The Respiratory System 7 known as pulmonary hemosiderosis. Lung Cancer Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs.
and workers exposed to halogenated ethers also have an increased incidence. Lung cancer is rarely caused directly by inherited mutations. Of the two basic forms. a persistent cough or wheeze. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. In countries with a prolonged history of cigarette smoking. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. In cases where the cancer has spread beyond the lungs. unexplained weight loss. Types of Lung Cancer Once diagnosed. Heavy smokers have a greater likelihood of developing the disease than do light smokers. chest pain. as do some workers in hydrocarbon-related processing. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. or bone pain may occur. According to the American Cancer Society. such as coal processors. visible lumps. Uranium and pitchblende miners. welders. tar refiners. The risk is also greater for those who started smoking at a young age. and susceptibility to lower respiratory infections. jaundice. Tumours can begin anywhere in the lung. small-cell 153 . secondhand smoke accounts for an estimated 3. The most common symptoms include shortness of breath. bloody sputum. between 80 and 90 percent of all cases are caused by smoking. and roofers. Other risk factors include exposure to radon gas and asbestos. chromium and nickel refiners.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75.400 deaths from lung cancer in nonsmoking adults in the United States each year. the tumour’s type and degree of invasiveness are determined.
SCLC is the most aggressive type of lung cancer. This tumour is characterized by flat. 154 . Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. but it is the most common type of lung cancer in the United States. peripheral bronchi. About 10 percent of all lung cancers are large-cell carcinomas. It is characterized by cells that are small and round. and it often develops in the larger bronchi of the central portion of the lungs. Treatment. Small-cell carcinoma (SCLC).7 The Respiratory System 7 carcinoma accounts for 20 to 25 percent of all cases and non-small-cell carcinoma is responsible for the remainder. oval. and both lungs or metastasis to other organs. Cells of adenocarcinoma are cube. There is some dispute as to whether these constitute a distinct type of cancer or are merely a group of unusual squamous cell carcinomas and adenocarcinomas. also called oat-cell carcinoma. Tumours often originate in the smaller. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. pleura. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. Because it tends to spread quickly before symptoms become apparent. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. the survival rate is very low. and Prevention Lung cancers are often discovered during examinations for other conditions. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. and large-cell carcinoma. and they form structures that resemble glands and are sometimes hollow. Cancer cells may be detected in sputum. Diagnosis. is rarely found in people who have never smoked.or column-shaped. adenocarcinoma. scalelike cells. also called epidermoid carcinomas. or shaped like oat grains.
Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . and radiation. and magnetic resonance imaging (MRI). a lobe of the lung (lobectomy). Surgery involves the removal of a cancerous segment (segmentectomy). Lung surgery is serious and can lead to complications such as pneumonia or bleeding.7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. For example. The choice of treatment depends on the patient’s general health. The type of treatment an individual patient receives may also be based on the results of genetic screening. abnormal fluctuations in the serum levels of parathormone or the presence in the blood of a protein called cytokeratin 19 fragment or of substances known as carcinogenic antigens may be indicative of malignant lung disease. Noninvasive methods include X-rays. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. or the entire lung (pneumonectomy). positron emission tomography (PET) scans. treatments for lung cancer include surgery. For this reason. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. lung cancer has a poorer prognosis than many other cancers. which can identify mutations that render some lung cancers susceptible to specific drugs. the five-year survival rate is about 50 percent. Even when it is detected early. the stage or extent of the disease. Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. chemotherapy. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. and the type of cancer. As with most cancers. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. computed tomography (CT) scans.
causing side effects that are similar to radiation therapy. Side effects include vomiting.7 The Respiratory System 7 following surgery to destroy small amounts of cancerous tissue. or additional damage to the lungs. noninvasive cysts of different kinds are also found in the mediastinum. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the 156 . together with the many important structures situated within it. particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. but these chemicals also attack normal cells to varying degrees. which relies on heat derived from microwave energy to kill cancer cells. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. Testing for radon gas and avoiding exposure to coal products. The probability of developing lung cancer can be greatly reduced by avoiding smoking. Chemotherapy uses chemicals to destroy cancerous cells. Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. Smokers who quit also reduce their risk significantly. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). and other airborne carcinogens also lowers risk. asbestos. Enlargement of lymph glands in this region is common. diseases of the MediastinuM and diaphragM The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. diarrhea. fatigue.
This area contains the heart. major blood vessels. there is no difficulty. Air bubbles can then enter the veins and capillaries of the circulatory system directly. the released air seeks an area of escape. One pathway that the air can follow is through the lung tissue into the mediastinum. Air trapped in the mediastinum expands as the diver continues to rise. If the diver breathes normally or exhales as he or she ascends at a moderate rate. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. This usually occurs as a result of lung rupture. mucus plugs. The pressure may cause intense pain beneath the rib cage and in the shoulders. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. If the diver holds his or her breath. The air the diver breathes is more dense and concentrated than the air breathed on the surface. and collapse blood vessels vital to circulation. which do not permit sufficient release of air. making breathing difficult. the external pressure upon his or her body increases. rises too rapidly. the expanding air may compress the respiratory passageways. While the diver remains deeply submerged. or has respiratory obstructions such as cysts. the extra gas pressure is relieved by exhaling. As a diver descends. or scar tissue. 157 . the external pressure decreases. main bronchi. and the trachea. when he or she begins to ascend again. however. causing an air embolism. the lungs become overinflated and rupture. or they can travel through the lung tissue to other areas of the body. and the lungs begin to expand because the air inside has less pressure to contain it. When the alveoli of the lungs rupture because of traumatic injury or lung disease.7 Diseases and Disorders of the Respiratory System 7 heart and central blood vessels. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity.
Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. respiratory failure. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. In some persons the diaphragm may be incompletely formed at birth. 158 . as occurs in emphysema.7 The Respiratory System 7 The symptoms of mediastinal emphysema may range from pain under the breastbone. bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. In many cases the cause of the paralysis cannot be determined. especially when the subject is recumbent (lying down). If there is respiratory or circulatory distress. For example. and cyanosis (blue colouring of the skin). although some shortness of breath on exertion is often present. In cases in which the symptoms are not severe. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air. the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. this can lead to herniation of the abdominal viscera through the diaphragm. shock. and shallow breathing to unconsciousness. diaphragmatic fatigue may limit the exercise capability of affected persons. the air will be absorbed by the body. The function of the diaphragm may be compromised when the lung is highly overinflated.
decompression sickness. altitude sickness. Respiratory function can be severely compromised by a variety of other conditions. traumatic conditions.CHAPTER6 ALLERGIC AND OCCUPATIONAL LUNG DISEASES AND ACUTE RESPIRATORY CONDITIONS llergic and occupational lung diseases comprise two groups of conditions that are associated with the exposure to and inhalation of particulate matter. the lungs are exposed to the outside environment. affected persons are highly sensitive to substances such as dust or pollen. leading to cancer and substantial loss of lung function. exposure to harmful irritants. however. For most affected persons. In some cases of occupational exposure. and. many of which are acute in nature. and drowning are other examples of acute conditions that can result in respiratory failure. hence. A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. such as asbestos and coal dust. For example. causes respiratory disease in otherwise healthy workers. reducing exposure to the irritant relieves the symptoms of their condition. In the case of allergies. 159 . require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. severe respiratory disease may ensue. such as respiratory distress syndrome. Carbon monoxide poisoning. In occupational disease. First.
Among adults. the walls of the bronchial tree contain smooth muscle that is very likely to be stimulated to contract if histamine is released by cells affected by the allergic reaction. aspirin. chest tightness. asthma may develop in response to allergens. dust mites. however. and breathlessness that range in severity from mild to life-threatening. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. such as pollen. women are affected more often than men. These substances provoke both allergic and nonallergic forms of the disease. and exercise may cause it as well. approximately half of all cases occur in persons younger than age 10. coughing. stress may exacerbate symptoms. or sinusitis. nasal polyps. When asthma develops in childhood. The most common and most important of these is asthma. and. Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. second. the lung contains a very large vascular bed. Asthmatic episodes may begin suddenly or may take days to develop. or animal dander. wood dusts. Adult asthma is sometimes linked to exposure to certain materials in the workplace. Adults who develop asthma may also have chronic rhinitis. In addition. In 160 . but viral infections. it is often associated with an inherited susceptibility to allergens— substances. causing episodes of wheezing. weather conditions. such as chemicals. third. boys being affected more often than girls. Although an initial episode can occur at any age. and grains. In adults.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. which may be involved in any general inflammatory response. that may induce an allergic reaction.
moderate persistent. symptoms will subside if the causative agent is removed from the workplace. most of these cases. terminal bronchial tubes. Encyclopædia Britannica. mild persistent. During an asthma attack. in general 161 . Consequently. air is obstructed from circulating freely in the lungs and cannot be expired. smooth muscles that surround the airways spasm. which results in tightening of the airways. which can be divided into four categories: mild intermittent. Asthma is classified based on the degree of symptom severity. and severe persistent.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. swelling and inflammation of the inner airway space (lumen) cause fluid buildup and infiltration by immune cells and excessive secretion of mucus into the airways. narrower passages (bronchioles) and finally into the tiny. Inc. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. Although the mechanisms underlying an asthmatic episode are not fully understood.
and leukotriene modifiers. or they may be used to provide rapid relief from constriction of airways (quick-relief medications). are in clinical trials. air is inspired but cannot be expired).g. These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi. These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). These 162 . theophylline). which interrupt the chemical signaling within the body that leads to constriction and inflammation. The inflamed. which suppress inflammation. swelling and inflammation of the bronchial tubes. Quick-relief medications may include bronchodilators. mucus-clogged airways act as a one-way valve (i.e. which are involved in mediating airway constriction and inflammation.7 The Respiratory System 7 it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system. The obstruction of airflow may resolve spontaneously or with treatment. such as shortacting beta2-agonists and ipratropium bromide. A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. Long-term control medications include corticosteroids. and zileuton and zafirlukast. Asthma medications are categorized into three main types: anti-inflammatory agents.. which are bronchodilators. and excessive secretion of mucus into the airways. which relax smooth muscle constriction and open the airways.. cromolyn sodium and nedocromil. bronchodilators. long-acting beta2-agonists and methylxanthines (e. or systemic corticosteroids. which are the most potent and effective anti-inflammatory medications available. which are anti-inflammatory medications often prescribed for children. which are leukotriene modifiers. Agents that block enzymes called phosphodiesterases.
However. exposure to secondhand smoke. crowded living conditions. A person with this condition must be hospitalized to receive oxygen and other treatment. which may cause cardiovascular damage. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. very few people are affected by allergies or asthma. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. the number of asthma cases has increased steadily.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 drugs are designed to be long-lasting—administered once per day via inhalation—and are expected to be safer than traditional medications. a species of hookworm. and even cockroaches have been blamed for the increase. can relieve symptoms of allergy and asthma. millions of people are infected with Necator americanus. The ability to recognize the early warning signs of an impending episode is important. In those areas. are not entirely clear. 163 . smoking. in many underdeveloped tropical regions of the world. particularly among children. Reasons for this dramatic surge in asthma cases. Today asthma affects more than 7 percent of children and about 9 percent of adults. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. too few to cause hookworm disease. In developed countries and especially in urban areas. Air pollution. A prolonged asthma attack that does not respond to medication is called status asthmaticus. Further investigation of this “helminthic therapy” in larger sample populations is under way. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma. In addition to managing asthma with medications.
is a common seasonal condition caused by allergy to grasses and pollens. Children who are given broad-spectrum antibiotics (effective against multiple microorganisms) before two years of age are three times more likely to develop asthma than are children who are not given such antibiotics. such as dermatitis or asthma. studies have indicated that only one vaccine. like other allergic diseases. chiefly those depending upon the wind for cross-fertilization. In a reverse scenario. such as ragweed in North America and timothy grass in Great Britain. and tearing and itching of the eyes caused by allergy to the pollen of certain plants. protection against asthma conferred by BCG vaccination (for defense against tuberculosis) has been proved only in children with a history of allergic rhinitis (hay fever). Antibiotics may also interfere with immune development. pertussis vaccine. The most effective long-term treatment is immunotherapy. Although not yet successfully confirmed. desensitization by injections of an extract of the causative pollen administered once or twice a week for one or more years. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. shows a familial tendency and may be associated with other allergic disorders. Seasonally recurrent bouts of sneezing.7 The Respiratory System 7 There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. also known as allergic rhinitis. Hay Fever Hay fever. 164 . In allergic persons contact with pollen releases histamine from the tissues. may give rise to asthma. which irritates the small blood vessels and mucus-secreting glands. Symptoms may be aggravated by emotional factors. Hay fever. nasal congestion.
Broman—Root Resources 165 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Giant ragweed (Ambrosia trifida) is a common cause of hay fever. Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America. Louise K.
In more chronic forms of the condition. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). after 166 . with inflammation of the smaller bronchioles. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. and there may be measurable interference with diffusion of gases across the alveolar wall. on the eastern seaboard of Canada. Variously known as pigeon breeder’s lung or bird fancier’s lung. or becoming opaque) in the basal regions of the lung on the chest radiograph. If untreated. This causes an acute febrile illness with a characteristically fine opacification (clouding. alveolar wall edema. Farmer’s lung is common in Wisconsin. may be found in the lung. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. particularly proteins contained in the excreta of pigeons. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). One of these illnesses is the so-called farmer’s lung. A similar group of diseases occurs in those with close contact with birds. budgerigars (parakeets). or aggregations of giant cells. with shortness of breath persisting after the radiographic changes have disappeared. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. in the west of England. Airflow obstruction in small airways is present.7 The Respiratory System 7 Hypersensitivity Pneumonitis Hypersensitivity pneumonitis is an important group of conditions in which the lung is sensitized by contact with a variety of agents and in which the response to reexposure consists of an acute pneumonitis. and in France. and canaries. these represent different kinds of allergic responses to proteins from birds. the condition may become chronic. granulomas.
The disease may present as an atypical nonbacterial pneumonia and may be labeled a viral pneumonia if careful inquiry about possible contacts with known agents is not made. or in response to a variety of other agents. Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. It is occasionally attributable to Aspergillus. occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Some species of the fungi genus Aspergillus can cause allergic reactions and mild pneumonia in susceptible individuals. but sometimes the precise agent cannot be identified.
Among inorganic dusts. Asbestos. and cough. clay.7 The Respiratory System 7 irritants. produce grave reactions. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. and infections of the already damaged lung can accelerate the disease process. barium. and emphysema in the most severe cases. beryllium. silica. notably silica and asbestos. of the lung. or air sacs. The total dust load in the lung. chromate. tin. and aluminum dusts can cause a more severe pneumoconiosis. usually over a prolonged period of time. Inhaled dust collects in the alveoli. chronic bronchitis. the early symptoms of mild pneumoconioses include chest tightness. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. Graphite. small quantities of some substances. encountered in numerous occupations. If enough scar tissue forms. is the most common cause of severe pneumoconiosis. although silica exposure is also involved in many cases. progressing to more serious breathing impairment. iron. The type and severity of disease depends on the composition of the dust. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. while milder irritants produce symptoms of lung disease only with massive exposure.2 ounce) in the lung can produce disease. As little as 5 or 6 grams (about 0. Typically. and the clinical symptoms of pneumoconiosis are manifested. and coal dusts are other inorganic substances known to produce pneumoconiosis. the toxic effects of certain types of dust. shortness of breath. often after relatively brief 168 . lung function is seriously impaired.
caused by fibres of cotton. flax. and buffing. Prolonged exposure to organic dusts such as spores of molds from hay. or hemp that. The 169 . and their irritant effect may cause large amounts of fluid to accumulate in the lungs. Brown lung disease in textile workers is also a form of pneumoconiosis. Chemical irritants that have been implicated in lung disease include sulfur dioxide. quarry workers. having been recognized in knife grinders and potters in the 18th century. when inhaled. which are quickly absorbed by the lining of the lungs. (Silica is the chief mineral constituent of sand and of many kinds of rock. The chemicals themselves may scar the delicate lung tissues. mushrooms. Histamines cause the air passages to constrict. Asbestosis has also been associated with cancers of the lung and other organs. acid. and chloride. the patient may recover completely or may suffer from chronic bronchitis or asthma.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 exposure to massive amounts of dust. sugarcane. and it remains one of the most common dust-induced respiratory diseases in the developed world. impeding exhalation. and barley can produce lung disease through a severe allergic response within a few hours of exposure. Once exposure to the chemical ceases. tunnelers. ammonia. nitrogen dioxide. sandblasting. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. stimulate histamine release. In most instances. Silicosis is one of the oldest industrial diseases.) The disease occurs most commonly in miners. Silicosis Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. and workers whose jobs involve grinding. malt. stonecutters. even in previously nonallergic persons. polishing.
The use of protective face masks and proper ventilation in the workplace and periodic X-ray monitoring of workers’ lungs has helped lessen the incidence of the disease. control of the disease lies mainly in prevention. is a respiratory disorder caused by repeated inhalation of 170 . called macrophages. however. and gas exchange is poor. The symptoms of silicosis are shortness of breath that is followed by coughing.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. though this has changed with the availability of drug therapies for that disease. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. cannot be digested by the macrophages and instead kill them. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses.000 particles of silica per cubic foot (about 210.000 per litre) of air. emphysema. Black Lung Black lung. the openings to the lungs. and weakness. and the abdominal lymph nodes. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. Silicosis predisposes a person to tuberculosis. These whorls of fibrous tissue may spread to involve the area around the heart.0004 inch) in diameter penetrate to the finer air passages of the lungs. There is no cure for silicosis. difficulty in breathing. Lung volume is reduced. since there is no effective treatment. and. and pneumonia. Silica particles.000. In the past a large proportion of sufferers of silicosis died of tuberculosis. and particles of one to three microns do the most damage. In the actual disease process. also known as coal-worker’s pneumoconiosis. that serve to protect the body from bacterial invasion. Only very small silica particles less than 10 microns (0.
brake linings. as coal dust often is contaminated with silica. It may be the best known occupational illness in the United States. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. and as a fire protectant sprayed inside buildings. first described lung disease in coal miners in the 16th century. whether coal itself is solely responsible for the disease. which produces characteristic changes in the lungs that can be identified in chest X-rays and that can impair lung function at an early stage. which causes similar symptoms. led to a virtual epidemic of asbestos-related disease 20 years later. and it is now widely recognized. Onset of the disease is gradual. tuberculosis is also more common in victims of black lung. The early stages of the disease (when it is called anthracosis) usually have no symptoms. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. Georgius Agricola. but it also occurs in soft-coal miners and graphite workers. and later in flooring. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to 171 . The first disease recognized to be caused by asbestos was asbestosis. and the extent of disease is clearly related to the total dust exposure. The disease is most commonly found among miners of hard coal. ceiling tiles. however. There is strong evidence that tobacco smoking aggravates the condition. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. It is not clear.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 coal dust over a period of years. a German mineralogist.
These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. there was a major increase in the risk for lung cancer. a blue asbestos that comes from South Africa. All 172 . thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. and. inhalation of asbestos remains a significant risk for the workers removing the material. is inhaled than if chrysotile is inhaled. Asbestos has been suspected to play a role in stimulating certain cellular events. all the respiratory changes associated with asbestos exposure are irreversible. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. Not all types of asbestos are equally dangerous. Malignant mesothelioma is rare and unrelated to cigarette smoking. but survival after diagnosis is less than two years. although in occasional cases pleuritis is very aggressive and thus may produce symptoms.7 The Respiratory System 7 thickening of the pleura. especially when associated with cigarette smoking. It is not yet understood exactly why asbestos devastates the tissues of the lungs. In most cases. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer. when both cigarette smoking and asbestos exposure occurred. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. The risk of mesothelioma in particular appears to be much higher if crocidolite. As far as is known. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. But exposure to any type of asbestos is believed to increase the risk of lung cancer.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.
Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing
The Respiratory System
beryllium alloys, and a slow-developing chronic disease occurring in scientific and industrial workers who are exposed to beryllium-containing fumes and dust. The acute disease involves both skin and lungs, causing a burning rash, eye irritation, nasal discharge, a cough, and chest tightness. The skin disease is caused by direct contact with beryllium salts and the lung disease by inhalation of metal dust or beryllium compounds. Most of those affected by acute berylliosis recover within a few months, but a small number of patients develop a highly fatal inflammation of the lung within 72 hours after a brief, massive exposure to beryllium. The chronic disease may occur more than 15 years after exposure, although the later it develops, the milder it is likely to be. It generally causes shortness of breath, especially after exercise, exhaustion, and a dry cough and can produce a permanent, though moderate, disability.
Byssinosis, or brown lung, is a respiratory disorder caused by inhalation of an endotoxin produced by bacteria in the fibres of cotton, flax, hemp, and other textiles. Byssinosis is common among textile workers, who often inhale significant amounts of cotton dust. Cotton dust may stimulate inflammation that damages the normal structure of the lung and causes the release of histamine, which constricts the air passages. As a result, breathing becomes difficult. Over time the dust accumulates in the lung, producing a typical discoloration that gives the disease its common name. Byssinosis was first recognized in the 17th century and was widely known in Europe and England by the early 19th century. Today it is seen in most cotton-producing
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
regions of the world. Several years of exposure to cotton dust are needed before byssinosis develops, and workers with lower grade disease usually recover completely upon leaving the industry or moving into an area with less dust. Persons with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure continues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Because cotton is by far the most common cause of byssinosis, this form of the condition has been variably known as cotton-dust asthma and cotton-mill fever.
Respiratory Toxicity of Industrial Chemicals
Toluene diisocyanate, used in the manufacture of polyurethane foam, may cause occupational asthma in susceptible individuals at very low concentrations. In higher concentrations, such as may occur with accidental spillage, it causes a transient flulike illness associated with airflow obstruction. Prompt recognition of this syndrome has led to modifications in the industrial process involved. Although the acute effects of exposure to many of these gases and vapours are well documented, there is less certainty about the long-term effects of repeated low-level exposures over a long period of time. This is particularly the case when the question of whether work in a generally dusty environment has contributed to the development of chronic bronchitis or later emphysema. In other words, whether such nonspecific exposures increase the risk of these diseases in cigarette smokers. Many chemicals can damage the lung in high concentration: these include oxides of nitrogen, ammonia,
The Respiratory System
chlorine, oxides of sulfur, ozone, gasoline vapour, and benzene. In industrial accidents, such as occurred in 1985 in Bhopal, India, and in 1976 in Seveso, near Milan, people in the neighbourhood of chemical plants were acutely exposed to lethal concentrations of these or other chemicals. The custom of transporting dangerous chemicals by rail or road has led to the occasional exposure of bystanders to toxic concentrations of gases and fumes. Although in many cases recovery may be complete, it seems clear that long-term damage may occur.
Disability and Attribution of Occupational Lung Diseases
Occupational lung diseases are of social and legal importance. In such cases, respiratory specialists must assess the extent of an individual’s disability and then form an opinion on whether an individual’s disability can be attributed to an occupational hazard. Pulmonary function testing and tests of exercise capability provide a good indication of the impact of a disease on the physical ability of a patient. However, it is much more difficult to decide how much of a patient’s disability is attributable to occupational exposure. If the exposure is historically known to cause a specific lesion in a significant percentage of exposed persons, such as mesothelioma in workers exposed to asbestos, attribution may be fairly straightforward. In many cases, however, the exposure may cause only generalized pulmonary changes or lung lesions for which the precise cause cannot be determined. These instances may be complicated by a history of cigarette smoking. Physicians asked to present opinions on attributability before a legal body frequently must rely on the application of probability statistics to the individual case, a not wholly satisfactory procedure.
Over time. This occurs most often during a postoperative period when the affected individual is immobilized in bed. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. Early mobilization after surgery or childbirth is considered an important preventive measure. The causative factors of these conditions may include accidents. when the infarction is massive. in which the pressure in the main pulmonary artery is persistently increased. conditions arising from exposure to extremes in atmospheric pressure. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. which has usually formed in the veins of the legs or of the pelvis. The consequences of embolism range from sudden death. to an increased respiratory rate. ranging from poor pulmonary circulation to carbon monoxide poisoning. When severe. a clot is replaced with 177 . and metabolic disorders. toxic gases. which occurs during mountain climbing and diving. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. comprise a diverse group of diseases and disorders. In addition. Circulatory Disorders The lung is commonly involved in disorders of the circulation. these changes are known as a pulmonary infarction. environmental pollutants. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. slight fever. and occasionally some pleuritic pain over the site of the infarction.
and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. lung transplantation is necessary.7 The Respiratory System 7 an adherent fibrous material in the pulmonary arteries. ultimately. The obstructing lesions can be surgically removed in some instances. When the 178 . a condition of unknown origin. While some medications such as calcium channel blockers may be taken orally. with consequent shortness of breath. right ventricular heart failure. usually after increasing disability with severe shortness of breath. In primary pulmonary hypertension. In addition to chest X-rays and basic pulmonary function tests. Prostacyclin can sometimes be given in oral or inhaled forms. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. usually as a consequence of coronary arterial disease. causing shortness of breath on exertion and. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. affected individuals require careful. follows left ventricular failure. long-term evaluation and treatment. In some cases. thereby relieving symptoms of breathlessness. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries.
5 pounds). which does the work of the lungs by oxygenating the 179 . The syndrome was formerly the leading cause of death in premature infants. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. Autopsies of children who had succumbed to the disorder revealed that the air sacs (alveoli) in their lungs had collapsed and a “glassy” (hyaline) membrane had developed in the alveolar ducts. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. In infants it is also called hyaline membrane disease. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. low-birth-weight infants (those weighing less than 2. These changes contribute to the shortness of breath and account for the blood staining of the sputum. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 valve between the left atrium of the heart and the left ventricle is thickened and deformed by rheumatic fever (mitral stenosis). Before the advent of effective treatment. particularly those born to diabetic mothers. Although respiratory distress syndrome occurs mostly in premature. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. This complication is especially common in premature newborns. or approximately 5.5 kg. It is characterized by extremely laboured breathing. it also sometimes develops in full-term infants. respiratory distress syndrome of infants was frequently fatal. cyanosis (a bluish tinge to the skin or mucous membranes). and abnormally low levels of oxygen in the arterial blood. The disorder arises because of a lack of surfactant.
7 The Respiratory System 7 blood and removing carbon dioxide. This episode spurred renewed attention to this problem. of the victims already had chronic heart or lung disease. Life-support treatment with assisted ventilation rescues many patients. although superimposed infection or multiple organ failure can result in death. Many. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. aspiration of material into the lung (including water in near-drowning episodes). Many causes of respiratory distress syndrome of adults have been identified. Most children who survive have no aftereffects. Recovery and repair of the lung may take months after clinical recovery from the acute event.000 people during that week and the subsequent three weeks. This syndrome is known as acute respiratory distress syndrome of adults. widespread bilateral lung injury. exposure of the lung to gases. bacterial or viral pneumonia. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. Air Pollution The disastrous fog and attendant high levels of sulfur dioxide and particulate pollution (and probably also sulfuric acid) that occurred in London in the second week of December 1952 led to the deaths of more than 4. Acute respiratory distress syndrome carries about a 50 percent mortality rate. which had been intermittently considered since the 14th century 180 . but not all. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. As the infant’s lungs mature and begin to produce surfactant—usually within three to five days after birth—the child is weaned from the ventilator. In adults.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 in England. the factor most responsible for the pollution. and finally the passage of legislation banning open coal burning. This begins with the emission Air pollution begins as emissions from sources such as industrial smokestacks. respiratory tract infections in the young and old. Photos. The large number of automobiles in that city. is associated with excess mortality and increased prevalences of chronic bronchitis. and possibly lung cancer. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. leads to the formation of photochemical smog. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories.com/Jupiterimages 181 . together with the bright sunlight and frequently stagnant air. common in many cities using coal as heating fuel. This form of pollution. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles.
and possibly the exacerbation of asthma occur as a result. The indoor environment can be important in the genesis of respiratory disease. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. including Mexico City. followed by the formation of nitrogen dioxide by oxygenation.12 part per million. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. 182 . and finally. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. Ozone is the most irritant gas known. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. and repeated exposures may lead to lung cancer. These levels are commonly exceeded in many places. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. Such exposures are common in the lives of millions of people. In developing countries. which begins as emissions of nitrogen oxides. and the impact of these exposures is an area of intense scientific investigation. In developed countries. Bangkok.7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. and São Paulo. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. Eye irritation. chest irritation with cough. through a complex series of reactions in the presence of hydrocarbons and sunlight. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds.
The carbon monoxide inhaled by smokers who smoke more than two packs of cigarettes a day may cause up to 10 percent hemoglobin saturation with carbon monoxide. a condition in which hemoglobin is deficient. 183 . leaving only 60 percent available to bind to oxygen). Judgment is also impaired. including combustion of gas in automobile engines. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. Carbon monoxide is produced by incomplete combustion. as part of his detailed analysis of atmospheres in underground mines. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. A 4 percent increase in the blood carbon monoxide level in patients with coronary artery disease is believed to shorten the duration of exercise that may be taken before chest pain is felt. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. For this reason.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. the subject feels dizzy and is unable to perform simple tasks.
in the body fluids. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. and renal failure. including the blood. Alkalosis and Hyperventilation Alkalosis is an abnormally low level of acidity. which may be caused by anxiety. congestive heart failure. or pneumonia. Metabolic acidosis occurs when acids are produced in the body faster than they are excreted by the kidneys or when the kidneys or intestines excrete excessive amounts of alkali from the body. Hyperventilation is defined as a sustained abnormal increase in breathing. asthma. Respiratory alkalosis results from hyperventilation.7 The Respiratory System 7 Acidosis Acidosis is an abnormally high level of acidity. This may be caused by severe acute or chronic lung disease. or bicarbonate gain. such as general anesthetic agents. pulmonary embolism. During hyperventilation the rate of 184 . or high level of alkalinity. shock. Alkalosis may be either metabolic or respiratory in origin. such as pneumonia or emphysema. or by certain medications that suppress respiration in excessive doses. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. in the body fluids. certain drugs or poisons. Metabolic alkalosis results from either acid loss. including the blood. There are two primary types of acidosis: respiratory and metabolic. among others. Causes of metabolic acidosis include uncontrolled diabetes mellitus. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. or low level of alkalinity.
accumulation of fluid in the alveolar spaces can interfere with gas exchange. Imbalances in the exchange of these gases can lead to dangerous respiratory disorders. Encyclopædia Britannica. 185 . causing symptoms such as shortness of breath. Inc.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. In addition. such as respiratory acidosis or hyperventilation.
The Respiratory System
removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, respiratory alkalosis ensues. In turn, alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, including light-headedness and tingling of the fingertips. Severe hyperventilation can cause transient loss of consciousness. Anxiety is the most common cause of hyperventilation. Panic disorder, a severe episodic form of anxiety, usually causes hyperventilation with resultant symptoms. Treatment of recurrent hyperventilation begins with a complete explanation by the patient of the condition and the symptoms it causes. Some people benefit from psychotherapy and medications to deal with the underlying anxiety.
Hypoxia is a condition of the body in which the tissues are starved of oxygen. In its extreme form, where oxygen is entirely absent, the condition is called anoxia. There are four types of hypoxia: (1) the hypoxemic type, in which the oxygen pressure in the blood going to the tissues is too low to saturate the hemoglobin; (2) the anemic type, in which the amount of functional hemoglobin is too small, and hence the capacity of the blood to carry oxygen is too low; (3) the stagnant type, in which the blood is or may be normal but the flow of blood to the tissues is reduced or unevenly distributed; and (4) the histotoxic type, in which the tissue cells are poisoned and are therefore unable to make proper use of oxygen. Diseases of the blood, the heart and circulation, and the lungs may all produce some form of hypoxia.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The hypoxemic type of hypoxia is due to one of two mechanisms: 1. a decrease in the amount of breathable oxygen—often encountered in pilots, mountain climbers, and people living at high altitudes— due to the reduced barometric pressure, or 2. cardiopulmonary failure in which the lungs are unable to efficiently transfer oxygen from the alveoli to the blood. In the case of anemic hypoxia, either the total amount of hemoglobin is too small to supply the body’s oxygen needs, as in anemia or after severe bleeding, or hemoglobin that is present is rendered nonfunctional. Examples of the latter case are carbon monoxide poisoning and methoglobinuria, in both of which the hemoglobin is so altered by toxic agents that it becomes unavailable for oxygen transport, and thus of no respiratory value. Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock. Local stagnant hypoxia may be due to any condition that reduces or prevents the circulation of the blood in any area of the body. Examples include Raynaud disease and Buerger disease, which restrict circulation in the extremities; the application of a tourniquet to control bleeding; ergot poisoning; exposure to cold; and overwhelming systemic infection with shock. In histotoxic hypoxia the cells of the body are unable to use the oxygen, although the amount in the blood may be normal and under normal tension. Although
The Respiratory System
characteristically produced by cyanide, any agent that decreases cellular respiration may cause it. Some of these agents are narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents.
Altitude sickness, sometimes called mountain sickness, is an acute reaction to a change from sea level or other lowaltitude environments to altitudes above 2,400 metres (8,000 feet). Altitude sickness was recognized as early as the 16th century. In 1878 French physiologist Paul Bert demonstrated that the symptoms of altitude sickness are the result of a deficiency of oxygen in the tissues of the body. Mountain climbers, pilots, and persons living at high altitudes are the most likely to be affected. The symptoms of acute altitude sickness fall into four main categories: 1. respiratory symptoms such as shortness of breath upon exertion, and deeper and more rapid breathing; 2. mental or muscular symptoms such as weakness, fatigue, dizziness, lassitude, headache, sleeplessness, decreased mental acuity, decreased muscular coordination, and impaired sight and hearing; 3. cardiac symptoms such as pain in the chest, palpitations, and irregular heartbeat; and 4. gastrointestinal symptoms such as nausea and vomiting. The symptoms usually occur within six hours to four days after arrival at high altitude and disappear within two to five days as acclimatization occurs. Although most
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
people gradually recover as they adapt to the low atmospheric pressure of high altitude, some persons experience a reaction that can be severe and, unless they return to low altitude, possibly fatal. At higher altitudes, the air becomes thinner and the amount of breathable oxygen decreases. The lower barometric pressures of high altitudes lead to a lower partial pressure of oxygen in the alveoli, or air sacs in the lungs, which in turn decreases the amount of oxygen absorbed from the alveoli by red blood cells for transport to the body’s tissues. The resulting insufficiency of oxygen in the arterial blood supply causes the characteristic symptoms of altitude sickness. The main protection against altitude sickness in aircraft is the use of pressurized air in cabins. Mountain climbers often use a mixture of pure oxygen and air to relieve altitude sickness while climbing high mountains. In addition, the prophylactic use of the diuretic acetazolamide initiated two to three days before ascent may prevent or mitigate acute altitude sickness. A more serious type of altitude sickness, high altitude pulmonary edema (HAPE), occurs rarely among newcomers to altitude but more often affects those who have already become acclimated to high elevations and are returning after several days at sea level. In pulmonary edema, fluid accumulates in the lungs and prevents the victim from obtaining sufficient oxygen. The symptoms are quickly reversed when oxygen is given and the individual is evacuated to a lower area.
Barotrauma and Decompression Sickness
Barotrauma is any of several injuries arising from changes in pressure upon the body. Humans are adapted to live at an atmospheric pressure of 760 mm of mercury (the pressure at sea level), which differs from pressures experienced
sinuses. however. face. When a pilot ascends to a higher altitude. the external pressures upon his or her body decrease. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. the pleural spaces. underwater divers. A fatal form of barotrauma can occur in submariners and divers. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). For example. and caisson workers are highly susceptible to the sickness because their activities subject them to pressures different from the normal atmospheric pressure experienced on land. In decompression sickness (also called “the bends” or caisson disease) the formation of gas bubbles in the body because of rapid transition from a high-pressure environment to one of lower pressure causes a variety of physiological effects. such as the eardrum. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. Pilots of unpressurized aircraft. In certain cavities of the body. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. and torso. in solution. lungs. and intestines. At atmospheric pressure the body tissues contain. small amounts of the gases that are present in the air. and these dissolved gases come 190 . Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. sudden expansion of air trapped within the thorax can burst one or both lungs. such as the ears. or under the skin of the neck. there are air pockets that either expand or contract in response to changes in pressure. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs).7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues.
Bubbles forming in the brain. Nitrogen is much more soluble in fatty tissue than in other types. Shallow. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). pain is usually severe and mobility is restricted. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). The pathogenesis of decompression sickness begins both with the mechanical effects of bubbles and their expansion in the tissues and blood vessels and with the surface effects of the bubbles upon the various components of the blood at the blood–gas interface. spinal cord.” The major component of air that causes decompression maladies is nitrogen. The term bends is derived from this affliction. If the ascent is slow enough. speech defects. Conversely. The gases then pass to the respiratory tract and are exhaled from the body. nausea. and personality changes. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s 191 . When the pressure decreases. When bubbles accumulate in the joints. The nervous system is composed of about 60 percent lipids. the “chokes. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. numbness. rapid respiration. Therefore.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 out of solution. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled. signals the onset of pulmonary decompression sickness. often associated with a sharp retrosternal pain on deep inspiration. as the affected person commonly is unable to straighten joints. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. the gases have time to diffuse from the tissues into the bloodstream. the excess nitrogen is released.
the air inside the lungs is compressed. Usually these symptoms pass in 10 to 20 minutes. As external pressure on the lungs is increased in a breath-holding dive (in which the diver’s only source of air is that held in his lungs). a burning sensation while breathing. the lung shrinks to about one-fourth its size at the surface. known as the chokes. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. Too much air causes rupture of lung tissue. and the size of the lungs decreases. It most commonly occurs during a breath-holding dive underwater.7 The Respiratory System 7 itches. Other symptoms include chest pain. If compression continues. If one descends to a depth of about 30 metres (100 feet). an increase in pressure causes air spaces and gas pockets within the body to compress. 192 . but this process is not always able to reverse damage to tissues. is a type of barotrauma involving compression of the lungs and thoracic cavity. indicate nitrogen bubbles in the respiratory system. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. Excessive coughing and difficulty in breathing. and the lung may collapse. Because the lung tissue is elastic and interspersed with tubules and sacs of air. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. The outer linings of the lungs (pleural sacs) may separate from the chest wall. or lung squeeze. During the descent. and severe shock. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. while too little air causes compression and collapse of the lung walls. Thoracic Squeeze Thoracic squeeze.
The sperm whale is reported to dive to about 1. but eventually it ceases. and their bodies are adapted to use the gases in the bloodstream more conservatively. Any symptoms of thoracic squeeze call for prompt medical attention. although they lack evidence of life. the diver may have difficulty in breathing. These aquatic mammals have been found to have more elastic chest cavities than humans. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. more than 10 times the depth that humans can tolerate. and may even become unconscious. loses consciousness. A fuller appreciation of the 193 . Until recently. It is now known that victims immersed for an hour or longer may be totally salvageable. usually water. even when reduced. Artificial respiration may be necessary if the breathing has stopped. may exhale frothy blood. do not separate from the chest wall. Deprived of oxygen the victim stops struggling. Animals such as seals and whales that descend to much greater depths than humans on a single breath of air have special adaptations to help them. There the heart may continue to beat feebly for a brief interval. the oxygen deprivation that occurs with immersion in water was believed to lead to irreversible brain damage if it lasted beyond three to seven minutes. physically and intellectually. their lungs. or breathing—at the time of rescue.000 metres (3. which can be relieved by ascending. Drowning Drowning is suffocation by immersion in a liquid. and gives up the remaining tidal air in his or her lungs. having no measurable vital signs—heartbeat.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The predominant symptom felt by the diver is pain when the pressure becomes too great. If the thoracic squeeze has been sufficient to cause lung damage. pulse.300 feet).
The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. in other respects it performs normally. When aspiration does occur. so that many people who once would have been given up for dead are being saved. In this suspended state. A natural biological mechanism that is triggered by contact with extremely cold water. Often. abdomen. 194 . despite a total absence of respiratory gas exchange. The mechanism is powerful in children. thus permitting seagoing mammals to hunt for long periods underwater. the volume of fluid entering the lungs rarely exceeds a glassful.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. enhances survival during submersion.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. Even though the heart functions at a slower rate. actual aspiration of water into the lungs may or may not occur. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. and surface areas of the body to the heart and the brain. Up to 15 percent of drownings are “dry. It diverts blood from the limbs. Scientists have determined that vestiges of the reflex persist in humans. known as the mammalian diving reflex.
Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia. and promotes unconsciousness. Immersion in icy water causes body temperature and metabolism to fall rapidly (the thermal conductivity of water is 32 times greater than that of air). Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. Such warmwater drownings occur commonly in domestic bathtubs. None of these effects is imminently life-threatening.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain.6 °F (17 °C) have survived. slows the heart rate. 195 . survival following hypothermic coma is almost 75 percent.” “Lifeless” immersion victims with core temperatures as low as 62.
Likewise. One of the most important advances in the history of respiratory medicine was the development of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. have contributed to improvements in the diagnosis and evaluation of respiratory disease. particularly concerning techniques employing X-ray imaging or endoscopy. physiology. This expansion of scientific understanding has enabled important progress in respiratory medicine. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. Today. or respiratory medicine. especially in the area of disease prevention. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. A cough productive of sputum is the most important manifestation of inflammatory or 196 . many technological advances. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. In addition.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. and pathology of the human respiratory system is known as pulmonology.
as when a foreign body is inhaled into the trachea. resulting from occupational lung disease or arising from no identifiable antecedent condition. and fluid may accumulate in 197 . More often. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. playing golf. of which bronchitis is a common example. This sensation. commonly. it is constantly present. Hemoptysis is also a classic sign of tuberculosis of the lungs. What is noted is a slowly progressive difficulty in completing some task. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. particularly in the first two hours after awakening in the morning. of complex origin. may also cause severe and unremitting dyspnea. or with the onset of a severe attack of asthma. the lung capillaries become engorged.7 Approaches to Respiratory Evaluation and Treatment 7 malignant diseases of the major airways. The second most important symptom of lung disease is dyspnea. The shortness of breath may vary in severity. such as walking up a flight of stairs. or walking uphill. but in diseases such as emphysema. capillary damage. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. Although it may result simply from an exacerbation of an existing infection. or shortness of breath. 30 to 60 ml of sputum are produced in a 24-hour period. and tasks such as dressing cannot be performed without difficulty. When this occurs. may arise acutely. or a tumour. in which there is irreversible lung damage. Severe fibrosis of the lung. it is insidious in onset and slowly progressive. and. if the right ventricle that pumps blood through the lungs is functioning normally. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. it may also indicate the presence of inflammation. It may become so severe as to immobilize the victim.
Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. diffuse 198 . a small lung cancer that is not obstructing an airway does not produce shortness of breath.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). Acute pleurisy with pain may signal a blockage in a pulmonary vessel. which leads to acute congestion of the affected part. such as a mesothelioma. of the toes) called “clubbing. and chest pain—may be added several others. This is caused by narrowing of the airways. a condition known as a pleural effusion. It is commonly dyspnea that first causes a patient to seek medical advice. To these major symptoms of lung disease—coughing. can cause pleurisy. since. Chest pain may be an early symptom of lung disease. such as occurs in asthma. for example. In addition. pulmonary embolism. pain of this severity is rare. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. The pain disappears when fluid accumulates in the pleural space. Fortunately. the occlusion of a pulmonary artery by a fat deposit or by a blood clot that has dislodged from a site elsewhere in the body. Severe. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. A wheeziness in the chest may be heard. severe chest pain may be caused by the spread of malignant disease to involve the pleura. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. but it is most often associated with an attack of pneumonia. For example. dyspnea. or by a tumour that arises from the pleura itself. but absence of the symptom does not mean that serious lung disease is not present. rarely.7 The Respiratory System 7 small alveoli and airways. Some diseases of the lung are associated with the swelling of the fingertips (and.
cerebral signs from intracranial metastases. unusual fatigue. and some symptoms apparently unrelated to the lung. especially in the early stage. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. Not infrequently. this unusual sign may disappear after surgical removal of the tumour. a hip fracture from bone metastases. as may sensory changes in the legs. Because the symptoms of lung disease. Not infrequently. may be conscious of only a general feeling of malaise. the patient may feel as one does when convalescent after an attack of influenza. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints. Thus. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. for example. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. particularly the small nodes above the collarbone in the neck. Methods of inVestigation Physical examination of the chest remains important. as it may reveal the presence of an area of inflammation. general psychological depression. In some lung diseases. or seemingly minor symptoms as the first indication of disease. a disinclination for physical activity. a 199 .7 Approaches to Respiratory Evaluation and Treatment 7 fibrosis of the lung from any cause. the first symptom may be a swelling of the lymph nodes that drain the affected area. are variable and nonspecific. such as mild indigestion or headaches. Loss of appetite and loss of weight. A person with active lung tuberculosis or with lung cancer. The generally debilitating effect of many lung diseases is well recognized. and lung cancer. In the case of lung cancer. may be diverse indicators of lung disease. since a peripheral neuropathy may also be the presenting evidence of these tumours.
in the case of ventilation scanning. percussion to gauge the resonance of the underlying lung. tender areas. sputum examination for malignant cells is occasionally helpful. a radioactive tracer molecule is either inhaled. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. and abnormal breathing patterns. The ventilation scan allows visualization of gas exchange in the bronchi and trachea. or an airway obstruction. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. or injected. or the pleural space. MRI is useful for imaging the heart and blood vessels within the 200 .7 The Respiratory System 7 pleural effusion. In these techniques. in the case of perfusion scanning. and the perfusion scan allows visualization of the blood vessels in the lungs. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). This technique produces a complete picture of the lungs by using X-rays to create two-dimensional images that are integrated into one image by a computer. because the technique is not well suited to imaging air-filled spaces. The sounds detected with a stethoscope may reveal abnormalities of the airways. Methods of examination include physical inspection and palpation for masses. and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds. While the resolution of computerized tomography is much better than most other visualization techniques. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. the lung tissue. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung.
and major bronchi. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. total ventilation. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. Tests of exercise capability. and after exercise. physicians can collect fluid and small tissue samples from the airways. and the rate of gas transfer across the lung. Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. Spirometry. which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). More complex laboratory equipment is necessary to measure the volumes of gas in the lung. are useful in assessing functional impairment and disability. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. and gas exchange are compared before. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. or the pressure required to inflate it. in which workload. the distribution of ventilation within the lung. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. By feeding a surgical instrument through a special channel of the bronchoscope. trachea. which is often used in field studies. the stiffness of the lung. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function.7 Approaches to Respiratory Evaluation and Treatment 7 thorax. 201 . during. Ventilatory capability can be measured with a peak flow meter. airflow resistance.
7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. and (2) those measuring respiratory function. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs). David McNew/Getty Images Pulmonary Function Test A pulmonary function test is a procedure used to measure various aspects of the working capacity and efficiency of the lungs and to aid in the diagnosis of pulmonary disease. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. Tests of ventilatory function include the following measurements: residual 202 . or the transfer of gas between the alveoli and the blood.
Chest X-ray X-ray imaging is a valuable diagnostic technique used in medicine. functional residual capacity (FRC). vital capacity. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. or air within the chest at the end of a quiet expiration. One of the most common screening roentgenograms is the chest film. and total lung capacity (TLC). and maximal expiratory flow rate (MEFR). taken to look for infections such as 203 . maximum air volume expelled in a time interval. maximum air volume that can be expelled after a maximum inspiration. all the other volumes may be recorded with a spirometer. volume of a breath. Ventilation tests. or capillaries. the resting lung volume. of the lungs. who discovered X-rays in 1895. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. Tests of respiratory function include the measurement of blood oxygen and carbon dioxide and the rate at which oxygen passes from the alveoli into the small blood vessels. Except for the residual volume. maximal air volume expelled in 12 to 15 seconds of forced breathing. breathing movements may also be registered graphically on a spirogram. This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. which is measured by a dilution method. which measure the capacity of the lungs to move air in and out. maximal flow rate of a single expelled breath. forced expiratory volume (FEV).7 Approaches to Respiratory Evaluation and Treatment 7 volume (RV). air volume within the chest in full inspiration. expressed in litres of air per minute. include maximal voluntary ventilation (MVV). tidal volume. air remaining within the chest after a maximal expiration.
Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. the blockage of one of the pulmonary arteries or of a connecting vessel. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. unfortunately. To track the movement of air. For the perfusion part of the scan. Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. thereby narrowing the passageway and hindering the flow of blood.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. but. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 . this technique is of little value in screening for lung cancer because the stage at which the disease is detectable by this method is too far advanced for treatment to be of value. or VQ (ventilation quotient) scan. A scanner that contains a radiation-sensitive camera is then used to collect images of the gamma rays emitted from the tracer as it circulates through the lungs. Pulmonary embolism is caused by a clot or an air bubble that has become lodged within a vessel or by the accumulation of fat along the inner walls of the vessel. This approach may be taken for patients with advanced or rapidly spreading lung cancer. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs.
or areas where the tracers become highly concentrated and therefore produce bright areas in the images. normal air and blood flow are reflected in the even distribution of tracers within the lungs. Nutrient deprivation renders the tissue highly susceptible to death. the tissues affected will be either oxygen. highlight places within the lungs where air or blood have accumulated abnormally. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan.or blooddeprived. including angiography. the levels of radioactivity are exceptionally low and pose a very small risk to patients. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent 205 . he or she may subsequently undergo more invasive procedures.7 Approaches to Respiratory Evaluation and Treatment 7 with technetium). In contrast. The appearance of hot spots. In both ventilation and perfusion scans. the ventilation and perfusion scans match for a person with healthy lungs. Although the tracers used in lung ventilation/perfusion scanning are radioactive. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism. In general. Thus. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. Bronchoscopy Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. and another set of images is taken with the scanner. a mismatch between the two scans is indicative of disease.
7 The Respiratory System 7 The trachea and major bronchi of the human lungs. Encyclopædia Britannica. 206 . Inc.
207 .. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. to deliver certain therapeutic agents directly into the lungs. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. In addition. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. Flexible scopes. and to assist in the placement of stents (tubes. They are used most often to examine the central airways when blockage by a foreign body is suspected and to resect diseased tissue in a procedure known as laser bronchoscopy. which enables large volumes of fluid (e. consists of a metal tube that has a wide suction channel. because of their ability to bend and twist. blood) to be removed during an examination. both flexible and rigid scopes have a channel through which instruments can be passed. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways.g.7 Approaches to Respiratory Evaluation and Treatment 7 cough or who are coughing up blood. known as a rigid bronchoscope. The second type of scope. The most frequently used scope consists of a flexible tube containing a bundle of thin fibre-optic rods that project light onto the tissues being examined. Bronchoscopy is also employed to remove foreign objects from the airways. they remain superior for specific applications. There are two types of bronchoscopes. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures.
mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. there are several important risks associated with the bronchoscopy procedure itself. the movement of a bronchoscope through the airways often scratches superficial tissues. causing them to bleed. Because the region of the mediastinum contains the heart. which can cause side effects in some people. rigid bronchoscopy. however. as well as a set of lymph nodes. trachea. Mediastinoscopy Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. upon waking. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs.7 The Respiratory System 7 Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. including nausea and vomiting. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). esophagus. and thymus gland. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity. because of the discomfort caused by the device. bleeding subsides without the need for medical intervention. serving as one of the primary 208 . In addition. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. necessitates the use of general anesthesia. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. causing a condition known as pneumothorax. In most cases. Bleeding is especially common following biopsy. which occurs when the instrument is not sanitized properly. In contrast. For example.
The biopsy samples are then investigated for evidence of abnormalities. This step of the procedure is known as mediastinotomy. immediately above the sternum. flexible instrument—is then passed through the incision and into the space between the lungs. During mediastinoscopy. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. Severe complications— such as bleeding. infection. Most patients recover within several days following mediastinoscopy. In cancer staging. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. a surgeon first makes a small incision in the patient’s neck.7 Approaches to Respiratory Evaluation and Treatment 7 methods by which tissue samples are collected from the mediastinal lymph nodes for the staging of lung cancer. 209 . including computerized axial tomography and positron emission tomography. light-emitting. Staging involves the investigation of cells to assess the degree to which cancer has spread. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. A mediastinoscope—a thin. and the procedure is associated with a very low risk of complications. This may also be performed for other tissues in the region that display signs of disease. such as abnormal growths or inflammation. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). By carefully maneuvering the scope in the space. particularly for cellular defects associated with cancer and for the presence of infectious organisms. the doctor is able to investigate the surfaces of the various structures. which is performed under general anesthesia.
or a fog (as in an oxygen tent or a croup tent). can also be administered in an inhaled mist by means of an ultrasonic nebulizer. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. hot steam. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. and antibiotics. Therapy may involve the administration of gases for inhalation. Chest percussion. Oxygen may be administered in controlled amounts to assist laboured breathing. Medications. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. A mixture of helium and oxygen is used to treat some diseases of airway obstruction. performed manually or by means of a handheld percussor or vest. such as bronchodilators. produces vibrations that help to loosen and mobilize secretions. There are different methods of treatment employed in respiratory therapy. Aerosol humidifiers called nebulizers may be powered by compressor machinery or by a hand-squeezed bulb to project medication or water spray into the airway. mucolytics. 210 . In addition. as in treatment of cystic fibrosis. and maintenance of mechanical ventilators. each of which may be tailored to a specific disease. adjustment. respiratory therapists are experts in the setup. One of the conditions frequently dealt with is obstruction of breathing passages. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam.7 The Respiratory System 7 types of respiratory therapy Respiratory therapy is primarily concerned with assisting or improving the respiratory function of individuals with acute or chronic lung disease. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions.
and larger arteries respond to some degree. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. they mimic the effects of stimulation of the sympathetic 211 . although capillaries. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. antihistamines. Decongestants are sympathomimetic agents. The constricting action chiefly affects the smallest arteries. there are three groups. the arterioles. That is. and antibiotics.7 Approaches to Respiratory Evaluation and Treatment 7 Drug Therapies There are many different types of drugs that may be used in the treatment of respiratory diseases. that are of particular importance in the routine treatment of respiratory illness. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. veins. and thus they are used by many people. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. thus reducing blood flow to the inflamed areas. decongestants and antihistamines are available over the counter. In countries such as the United States. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. decongestants. When administered in nasal sprays or drops or in devices for inhalation. The relative safety and efficacy of these drugs has made them generally reliable medications. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. due to the emergence of resistant organisms. However.
an alkaloid originally obtained from the leaves of ma huang. or heart palpitations. inflammation. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . They include phenylephrine hydrochloride. following its release from certain large cells (mast cells) within the body. Because none of them has a sustained effect. and allergy. however. they must be used repeatedly.7 The Respiratory System 7 division of the autonomic nervous system. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. thereby preventing histaminetriggered reactions under such conditions as stress. insomnia. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. and naphazoline hydrochloride. The effectiveness of the other decongestants results from their chemical similarity to epinephrine.000 years. dizziness. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. amphetamine and several derivatives. causing anxiety. headache. One of the chief drugs of the group is epinephrine. Ephedrine and other decongestants are made by chemical synthesis. any of several species of shrubs of the genus Ephedra. results in absorption into the bloodstream. The oldest and most important decongestant is ephedrine. too frequent use. in which epinephrine constricts the blood vessels of the skin. which has been used in Chinese medicine for more than 5.
headache. among them hay fever and seasonal rhinitis. nearly all antihistamines produce undesirable side effects. and most are rendered inactive by monoamine oxidase enzymes in the liver. If a patient’s condition does not improve after three days of treatment with antihistamines. The first antihistamines were derivatives of ethylamine. compounds that were more potent. blurred vision. Nasal irritation and watery discharge are most readily relieved.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. The most common side effect in adults is drowsiness. it is unlikely that he or she will benefit from them. Other side effects include gastrointestinal irritation. Antihistamines are readily absorbed from the alimentary tract. and certain sensitivity reactions respond well. itching. subsequently. and less toxic were prepared. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. edema. 213 . and dryness of the mouth. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. The development of these antihistamines dates from about 1937. Used in sufficiently large doses. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. more specific. In 1942. were too toxic for clinical use. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. Antihistamines are not usually beneficial in treating the common cold and asthma. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. tested later and found to be more potent. Anilinetype compounds. More than 100 antihistaminic compounds soon became available for treating patients. Persons with urticaria. antihistamines can control certain allergic conditions.
Antibiotics known as macrolides (e. are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era. Macrolides. act against a broad spectrum of different bacteria. clarithromycin. at a high enough concentration to be effective (but not cause side effects). Antibiotics vary in their range of action.. whereas others. which inhibit bacterial protein synthesis.g. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. and for a sufficient length of time to ensure that the infection is totally eradicated. Some are highly specific. such as the tetracyclines. Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). cimetidine (Tagamet) was introduced.7 The Respiratory System 7 During the 1970s an H2-blocking agent. and they are especially important in the treatment of bacterial respiratory infections. Oxygen Therapy The medical administration of oxygen is an important means of treating respiratory disease. the bacillus responsible for diphtheria. Compounds of this class suppress histamine-induced gastric secretion and have proved extremely useful in treating gastric and duodenal ulcers. erythromycin. but they can be given parenterally. in which tissues such as the 214 . These drugs are usually administered orally. azithromycin) are particularly effective in the treatment of bacterial respiratory infections. Oxygen therapy is used for acute conditions.
which is inserted directly into the trachea by way of a hole made surgically in the neck.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. Another form of therapy. In both the hospital and the home settings. HBOT has been promoted as an alternative therapy for certain conditions. such as chronic obstructive pulmonary disease (COPD). a device inserted into the nostrils that is connected by tubing to an oxygen system. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. In addition. oxygen may be delivered through a face mask or through a nasal cannula. The high-pressure atmosphere has been shown to reduce air bubbles in the blood of persons affected by conditions such as air embolism (artery or vein blockage by a gas bubble) and decompression sickness. however. portable compressed-gas oxygen cylinder. For patients affected by chronic lung diseases. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. These applications are controversial. In emergency situations. known as hyperbaric oxygen therapy (HBOT). Some patients may require oxygen administration via a transtracheal catheter. oxygen may be administered by citizen responders via mouth-to-mouth breaths in cardiopulmonary resuscitation (CPR) or by emergency medical personnel via a face mask placed over the victim’s mouth and nose that is attached to a small. the high concentrations of oxygen made available to tissues have been shown to help stimulate the growth of new blood vessels (angiogenesis) in healing wounds and to slow the progression of infections caused by certain anaerobic bacteria. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). 215 . home oxygen therapy may be prescribed by a physician.
Large stationary and small portable gas cylinders can be used in the hospital or the home. Gas cylinders are often used in conjunction with oxygenconserving devices that prevent oxygen leakage from the cylinder by releasing gas only when the patient inhales. and carbon dioxide levels are measured. a measure known as the flow rate. When it is released under pressure from cold storage. Oxygen also can be stored as a highly concentrated liquid. oxygen. Liquid oxygen can be stored in small or large insulated containers. Stationary and portable oxygen concentrators have been developed for use in the home. In the ABG test. and blood acidity. In pulse oximetry. The stored oxygen can then be used by the patient when needed and is readily replenished. Another form of oxygen storage is in compressed-gas cylinders. which necessitates more-frequent cylinder replacement. Oxygen concentrators. which maintain oxygen under high pressure and require the use of a regulator to modulate the flow of gas from the cylinder to the patient. Oxygen is usually administered in controlled amounts per minute. a probe. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood 216 . which draw in surrounding air and filter out nitrogen. provide a method of storing oxygen at concentrations greater than that occurring in ambient air.7 The Respiratory System 7 There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. Flow rate is determined based on measurements of a patient’s blood oxygen levels. it is converted to a gas. generally placed over the end of a finger. Oxygen turns to liquid only when it is kept at very cold temperatures. blood is drawn from an artery. Two tests that are commonly used to assess the concentration of oxygen in the blood include the arterial blood gas (ABG) test and the pulse oximetry test. which can be refilled at pharmacies or by delivery services. as opposed to releasing gas constantly.
such as with the drug bleomycin. a chronic disorder affecting infants. Also. For example.7 Approaches to Respiratory Evaluation and Treatment 7 that are carrying oxygen. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. Compressed-gas cylinders present a significant safety hazard in the home as well. If oxygen flow rate is too low. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. it does not appeal to some patients. if they are not secured and stored 217 . oxygen therapy does not alter the progression of lung disease. leading to the damage of healthy tissues. HBOT is associated with an increased risk of barotrauma of the ear. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. adverse physiological effects may ensue if the flow rate is too high. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. Excess oxygen flow also can result in conditions such as barotrauma. For example. Likewise. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. which can lead to tissue dysfunction and cell death. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. a response that is amplified in the presence of excess oxygen. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. Bronchopulmonary dysplasia. However. In general.
and electric shock. The person using mouth-to-mouth breathing places the victim on his back. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. clears his mouth of foreign material and mucus. Such techniques. choking. Furthermore. lifts the lower jaw forward and upward to open the air passage. Likewise. establishing and maintaining an open air passage from the upper respiratory tract (mouth. candles. strangulation. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. if applied quickly and properly. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. or other sources of ignition. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. carbon monoxide poisoning. can prevent some deaths from drowning. they may cause explosions. Artificial Respiration Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. oxygen can readily spread fire.7 The Respiratory System 7 properly. throat. which has been found to be more effective than the manual methods used in the past. 218 . and pharynx) to the lungs and 2. suffocation. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1.
Stockbyte/Getty Images 219 .7 Approaches to Respiratory Evaluation and Treatment 7 Mouth-to-mouth breathing is the most effective means of manual artificial respiration.
such as chest X-rays or computerized axial tomography chest scans. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. including infectious organisms. and spleen. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. tumours. the abnormal accumulation of fluid in the pleural space. Thoracentesis Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. liver. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. permitting the victim to exhale. and lung infections. such as tuberculosis and pneumonia. including pleural empyema. It is most often used to diagnose the cause of pleural effusion. Prior to thoracentesis. For diagnostic applications. The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion. particles such 220 . a needle is inserted through the chest wall and into the effusion site in the pleural space.7 The Respiratory System 7 and clamps the nostrils. If the victim is a child. including the lungs. Once the needle is inserted. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. In the subsequent thoracentesis procedure. as well as to prevent further complications associated with the condition. the results of chest percussion and imaging tests. including heart failure. the rescuer may cover both the victim’s mouth and nose. He then alternately breathes into the victim’s mouth and lifts his own mouth away.
and wounds that are difficult to heal. In its simplest form. for several hours afterward patients are often observed for the manifestation of adverse effects.7 Approaches to Respiratory Evaluation and Treatment 7 as asbestos. also known as a decompression chamber (or recompression chamber). Experimental compression chambers first came into use around 1860. which occurs when a needle punctures the lungs. However. another breathing mixture. gas embolism. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks. generally lasting about 10 to 15 minutes. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate.. which are suggestive of mesothelioma or lung cancer. coagulopathy). Thoracentesis is contraindicated in persons with bleeding disorders (i. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. the accumulation of air in the pleural space. More serious complications include pneumothorax. and aberrant stimulation of the vasovagal reaction. Pressures 221 . carbon monoxide poisoning. gas gangrene resulting from infection by anaerobic bacteria. the hyperbaric chamber is a cylindrical metal or acrylic tube large enough to hold one or more persons and equipped with an access hatch that retains its seal under high pressure. Minor complications associated with thoracentesis include pain and cough. Thoracentesis is a relatively quick procedure. Hyperbaric Chamber A hyperbaric chamber.e. and tumour cells. Air. The results of these analyses frequently warrant further diagnostic testing. particularly upon detection of cancerous cells. tissue injury arising from radiation therapy for cancer. leading to a drop in blood pressure and fainting (syncope).
7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. 222 . In the treatment of carbon monoxide poisoning. or from a combination of the two. which increases oxygen availability to the body in therapeutic treatment. for example. In the treatment of decompression sickness. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen).5 to 3 times higher than ordinary atmospheric pressure. Chris McGrath/ Getty Images used for medical treatment are usually 1. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues.
many people who die of severe head injuries. Persons severely disabled by cystic fibrosis. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. the techniques are being pursued aggressively in specialized centres. respiratory medicine has continued to fulfill a vital role in advancing scientists’ understanding of respiratory disease and of the basic cellular and molecular processes that contribute to the normal function of the 223 . survival at one year has been reported at 90 percent. Availability of donor lungs is sharply limited by the number of suitable donors. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. With proper selection of donor organs and proper transplantation technique. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. emphysema. sarcoidosis. conclusion In the 21st century. but from the late 1970s bilateral lung transplantation had some striking results. for example. Because transplantation offers the only hope for persons with severe lung disease.7 Approaches to Respiratory Evaluation and Treatment 7 Lung Transplantation Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. who may be relatively young. pulmonary fibrosis. often have also suffered lung injury or lung infection. which presumably would leave the lungs intact. Brochiolitis obliterans and the constant risk of serious infection brought about by the use of immunosuppressant drugs limit survival to approximately 40 to 60 percent five years after surgery.
and similar preventable respiratory afflictions. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. However. In many countries.7 The Respiratory System 7 respiratory system. sometimes drastically increasing their ability to infect and cause disease in humans. basic knowledge of the viruses that cause the common cold eluded scientists. 224 . and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. The negative influence of behaviours such as tobacco smoking on lung function is now well documented. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. For decades. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. mesothelioma. which are the most frequent cause of the common cold. Such progress promises to reduce the global mortality of lung cancer. with health and environmental concerns at the forefront. Influenza viruses circulate globally. In fact. The genetic information was being used to establish an understanding of the relationships between the dozens of common-cold rhinoviruses and was expected to provide new insights that could potentially lead to the development of diagnostic tests and possibly even new drugs or vaccines. acquiring genetic mutations that alter their infectious characteristics. in 2009 researchers reported having mapped the genetic codes of rhinoviruses.
As researchers and physicians continue to uncover new information about the human respiratory system. For example.7 Approaches to Respiratory Evaluation and Treatment 7 Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease. In addition. the identification of disease-associated metabolic changes within cells and tissues has played an important role in the development of various functional and diagnostic tests. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. 225 . discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. as well as new treatments. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests.
hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. glottis A sagittal slit formed by the vocal cords. hypercapnia Excess carbon dioxide retention. Act on the larynx as a whole. 226 . or transformation of glucose into energy. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. moving it upward or downward. during the act of swallowing. Also known as a decompression chamber or recompression chamber. glycolysis Fermentation.GLOSSARY apnea Cessation of breathing. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. controls the traffic of air and food. functions as a lid to the larynx and. leaf-shaped flap. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. convection The transfer of heat by movement of a heated fluid such as air or water. epiglottis Cartilaginous.
purulent Pus-producing. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. surfactant Substance that. resulting in the development of secondary tumours. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. paranasal sinuses Cavities in the bones that adjoin the nose. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. a thin membranous sac encasing each lung. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung.7 Glossary 7 hypoxia Reduction of oxygen supply to tissues to less than physiological levels. when added to a liquid. metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. pleura In humans. reduces its surface tension. and tension of the vocal cords. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. neuraminidase A glycoprotein on the surface of influenza viruses. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. thereby increasing its spreading and wetting properties. rhinitis Inflammation of the mucous tissue of the nose. 227 . and as the organ of phonation. length.
(1977–79). (2001). The human respiratory system is described in David V. Elliott (eds. Abnormal breathing during sleep is covered by Nicholas A. 2nd ed. Murray. Altose and Yoshikazu Kawakami (eds.). 4th ed. Sullivan (eds. Berger. Peter T. (2008). Sleep and Breathing. Bennett and David H. The effects of swimming and diving on respiration are detailed in Peter B. Diagnosis of Diseases of the Chest. Christie. and Jerome A. (1993). Fraser et al. Bates. Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. Hlastala and Albert J.). and Robert G. Pack (eds. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. Corwin Hinshaw and John F. (1971).BIBLIOGRAPHY Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. Control of breathing is described in Murray D. 4th ed. and Ronald V.).. 2nd ed. 228 . (1995). HighAltitude Medicine and Pathology. (1988). a detailed text on impairment of lung function caused by disease. Dempsey and Allan I. Fishman and Jack A.. Macklem. Saunders and Colin E. 1 also available in a 3rd ed. with vol.). The Respiratory System (2003). (1995). 4th ed. Physiology of Respiration. H. 2nd ed. and Michael P. 4 vol. (1994). The Physiology and Medicine of Diving. Elias. Fishman’s Pulmonary Diseases and Disorders. ed. Control of Breathing in Health and Disease (1999). 2nd. Regulation of Breathing. 2nd ed.
Fishman (ed. Churg et al. provides a comprehensive overview of pathophysiology as related to clinical syndromes. (1988). 2nd ed. (1980). Bateman. Thurlbeck’s Pathology of the Lung. 3rd ed. Textbook of Respiratory Medicine. John Crofton and Andrew Douglas. Weinberger. and Ian R. G. (1980). Semple. is a general textbook covering diagnosis and treatment of chest diseases. Principles of Pulmonary Medicine.. 3 vol. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. (eds.). Comprehensive texts include Gordon Cumming and Stephen J. 3rd ed.). Scadding and Gordon Cumming (eds. Steven E. Pulmonary Diseases and Disorders. see also J. Alfred P. 2nd ed. (1994). and Andrew M. (1981). Murray and Jay A. Disorders of the Respiratory System. 229 .). (1998). Respiratory Disorders (1983). 2nd ed. (2005). Nadel (eds. Respiratory Diseases. 4th ed. 3rd ed. See also John F.).7 Bibliography 7 Diseases of the Chest. Cameron and Nigel T. Scientific Foundations of Respiratory Medicine (1981).
130–131. 111. 147. 174–175 C cancer. 218–220 asbestos. 118–119 air–blood barrier. 152. 169. 75 acidosis. 50 Breuer. 117. 34–35 amantadine. 136. 171. 123.INDEX A acid–base balance. 197. 188 bird fancier’s lung. 184–186 altitude sickness. 48 apnea. 209 animals. 171 AIDS. 172. 111. 153. 96. 124–125. 30. 92. 171 antibiotics. 230 . 168–169. 196. 205–208 brown lung. 217 bronchoscopy. 115. structure and function of. structure and function of. 30. 38. 187 byssinosis. 208. 171–173. 187 anesthesia. 46. 169. 51. 97. 181. 194 asthma. 127. 198 bronchioles. 111 Adam’s apple. 74. 214 antihistamines. Georgius. 126 arterial gas embolism. 169. 93. 135. 35. structure of. 116. 223 bronchitis. Paul. 33–34 bronchiolitis. 168. 127. 175. 171–173 asphyxiation. 75. 137. structure of. 221 asbestosis. 106 bradykinin. 73. 33–34 stem. 184 Actinomyces. 122. 100–102. 160–164. 81. 76. 134. 175. 49 bronchi. 85 artificial respiration. 131. 94. 131–133. 42. 137. 39 alcoholism. 129. 184. 170–171 Bordet. 217 Bert. 114. 173. 77 Agricola. 210. 86. 110. 193 anthracosis. 182. 81. 112–113. 64. 189–192. 197 bronchopulmonary dysplasia. 169 lung. 152. 46. Jules. 174 Buerger disease. 141–144 B barotrauma. 176. 166 black lung. 212–214 aortic body. 186. 213 atelectasis. 79–80. 103 anemia. 99–100. 52. 103. 188–189 alveoli. 28–29 bronchiectasis. 113 alkalosis. 52. 164. 107. 109. 159. 27 adenosine triphosphate (ATP). 152–156. Josef. 108. 211. 102. 30. 211. 91. 159. 198.
112. 117. 145–148. 183 hay fever. 47. 164. 192. 85. 211–212 diaphragm. 214 diving. 213 hemoglobin. 217 Clara cells. 131. 161. 221. 160 HIV. 79–81. 187. Ewald. 92. John Scott. 25. 150 epiglottis. 56. 170. 52 chloride shift. 137. 98. 122. 80. 27. 93. 97. 63. 72 diphtheria. 136. 190. abnormal. 136–138. 189–192. 49 Hering-Breuer reflex. 159. 88 corticosteroids. 199. 215 carotid body. 87. 221 cardiopulmonary resuscitation (CPR). 21. common. 183. 149. 197. 98. 47. 156–158. 30. 218 dyspnea. 191–193 drowning. 135. 81. 106. 210. 129. 87. 137. 223 eosinophilic granuloma. 168. 67 chronic obstructive pulmonary disease (COPD). 198. 75–78. 222 decongestants. 91. 34 cold. 52 Cheyne-Stokes breathing. 174. 98–99 epiglottitis. 119 231 . 64. 143. 127–129. 158 diffusion limitation. 197–198 H Haldane. 69. 44. 81 central nervous system disease. 182 G gas exchange. 105–106. 94. 75. 130.7 Index 181. 50. Octave. 111. 98–99 epinephrine. 66. 74 goblet cells. 137. 65. 158. 115. 177. 196. 156. 201. 64. 190 histamine. 84. 198 croup. 50. 65. 220. 138. 96. 49 high altitudes. 48. 209. 106. 47. 95. 130. 86. 184. 188–189. 212 exercise (training). 62. 81–86. 133–136. 58–59. 187. 25. 196–197. 216–217 Hering. 84. 186. 69–72 Gengou. 215. 151 D decompression sickness. 159. 132. 94. 144. 30 Goodpasture syndrome. 95. 197. 175. 207 physiology of. 164 coughing blood. 46. 182. 213 cause of. 201 F farmer’s lung. 132 types of. 80. 106 glycolysis. 98–99 cystic fibrosis. 145. 122. 98. 108. 147. 78. 157–158. 60. 211. 102. 67. 204. 50. 171. 223 7 E emphysema. 183. 51–52. 193–195. 88–91. 190. 180. 215. 130. 166 fungi. 78. 122.
7 The Respiratory System 7 hookworm. 26 232 . 149 influenza. 83 hypersensitivity pneumonitis. 171–173. 127. 172. 186–188 I idiopathic pulmonary fibrosis. 104 vaccine. 87. 31 transplantation of. 126 hypoxemia. 166–167 hyperventilation. 149. 46–48. 198. 144–145. 176. 221 metabolism. 87. 26–28 Legionnaire disease. 49. 94 nerves laryngeal. 198. 100 lungs N nephritis. 204–205 M measles. 117 mesothelioma. 69. 74. 147. 81–82. 221 collapse of. 93. 95–96 larynx. 197 development of. 114–115. 94. 88. 149. 159 congestion of. 47. 138. 177 size of. 125 hypoventilation. 99. 38–40 infarction. 215. 173 cancer of. 119 hyperbaric chamber. 50 meningitis. 110. 143. 81 mountain sickness. 217 hypoxia. 113–114. 135–136. 127. 127 hygiene. 199 bird flu. structure and function of. 78 anaerobic. 41. 181. 184 L Laënnec. 73–78. 99 mediastinoscopy. 156–158. 209. 215. 145 K kidney. René-ThéophileHyacinthe. 128. 83. 37. 52. 208 medulla. 173. 31. 152–156. 70. 96. 196 laryngitis. 103 H1N1. 141. 138. 45. 163 hydrothorax. 91. 182. 169. 81 aerobic. 167. 117. 204. 184–186 hypothyroidism. 76–77. 92. 102–105. 76 Monge disease. 199. 122. 55–56. 110. 81 mucoviscidosis. 44. 26. 214 leukemia. 68. 103. 208–209 mediastinum. 139. 98. 114. 38. 150. 178. 50. 151. 173. 138–141. 190. 129. 74. 221–222 hypercapnia. 223 lung ventilation/perfusion scan. 178. 51–52.
168–169. 131. 103. 211. 33. 50 nitrogen narcosis. 31–32. 139. 180–182 pons. 103. 170 pneumonia. 103 Röntgen. 194 pulmonary parenchyma. 108–113. 214 pharynx. 200. 198. 26. 88 rimantadine. 150–151 pulmonary edema. 99 Index 7 O obesity. 22. 214–218 128. 50. 91. 180. 92–94. 184. 208. 95 shunting. 104 osteoporosis. 149–150. 198. 169–170 sinuses. 220 pleurisy. 189. 91. 111 parrot fever. 223 scarlet fever. 159. 130. 211. 44 Pontiac fever. 122 function of. 152. 108. 93 sinusitis. 167. 160 sleep. 104–105 respiratory distress syndrome. 214 pertussis. 113. 128. 172.7 olfactory. 87. 164 pharyngitis. 118 prostaglandins. 114 Pott disease. 164 inflammation of. 36. 93 congestion of. 126. 56. 24–25 pickwickian syndrome. 170. 179 rheumatoid arthritis. 155. 95. 110 pulmonary alveolar proteinosis. 208. 138. 173. 107. 89 structure and function of. 141. 88. 126–130. 117. 178. 91. 50 psittacosis. 126. 137. 154. 93. 103. 122. 179–180 Reynaud disease. 100 rhinoviruses. 198 pleural effusion. 124. 114. 38. 125. 87. 107–108. 21–24. 41. 92. 128 R Relenza. 105–106. 69–71 silicosis. 94. 214. 19. 203 P parasites. 22 irrigation of. 34 pyothorax. 53. 85 nose cilia. 220 pneumothorax. 136 233 .Wilhelm Conrad. 221 pollution. 47 vagus. 52–53. 127. 198 pneumoconiosis. 92. 33. 146. 23–24 sinus. 187 rheumatic fever. 129–130. 137 oxygen therapy. 126 pleura. 209. 87. 57. 126 oseltamivir. 84. 85. S sarcoidosis. 91–92. 139. structure and function of. 136. 107 penicillin. 108. 127–129. 106. 127. 107. 45.
87. 127–129 thoracic squeeze. 130. 87. 25. 81–86 syphilis. 97. 220–221 thoracic emphyema. 163. 99. 116. 96–98 trench mouth. 175. 28–30 tracheitis. 99. 143. 97. 131–132. 106. 164. 69 vestibular folds. 95. 192–193 tonsillitis. 138. 91. 220 typhoid. 94 smoking. 111. 118. 103. 105–107 Z zanamivir. 104–105 234 . 136. 53. 103. 209 swimming. false. 91 vocal chords. 97 smell. 171. 218 sneezing. 109. 199. 108. 197. 155–156. 33. 103. 95. 92. 164. 94. 138. 198. 124 W whooping cough. 133–135. 214 surgery. 92 streptococcal bacteria. 137. 96. 172. 21. 182. 110. 87. 97 trachea. 96. 53. 91. 123. 92. 183. 56. 122. 104 tetanus. 92.102. 91. 92. 106 thoracentesis. 119. 150. 146 strep throat. 97. 128. 97 V vaccination. 178. 23–24. 199. 92. 204.7 The Respiratory System 7 smallpox. 122. 102. 170. 58 ventilation–blood flow imbalance. 27–28 vitamin C. 27–28 T Tamiflu. 176. 94–95. 93. structure and function of. 114–121. 78. 138. 94 staphylococci. 173 Valsalva maneuver. 164 snoring. 125. 208. 94–95 tonsils. 130. 152. 107. 123–124 sore throat. 171. 95. 129. 97. 153. 88. 93. 95 tuberculosis.
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