This action might not be possible to undo. Are you sure you want to continue?
E. First Edition Britannica Educational Publishing Michael I. Levy: Executive Editor J. Luebering: Senior Manager Marilyn L. call toll free (800) 237-9932. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. 196. Encyclopædia Britannica. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. Distributed exclusively by Rosen Educational Services. Rogers. 159. Copyright © 2011 Encyclopædia Britannica. © www.istockphoto. Media Acquisition Kara Rogers: Senior Editor. For a listing of additional Britannica Educational Publishing titles. I. Production Control Steven Bosco: Director. Biomedical Sciences Rosen Educational Services Heather M. cm. p. and the Thistle logo are registered trademarks of Encyclopædia Britannica. Britannica. 230: A healthy set of lungs is the powerhouse behind the respiratory system.com / nicoolay . LLC 29 East 21st Street. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. Kara. Inc. 228. ISBN 978-1-61530-147-8 (library binding) 1.” Includes bibliographical references and index. NY 10010. 87.2—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. 41. Chip Somodevilla/Getty Images On pages 19. New York. Editorial Technologies Lisa S. 122. Inc. All rights reserved.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. -.) in association with Rosen Educational Services. Inc. Barton: Senior Coordinator. 226. LLC. © www.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. Rosen Educational Services. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. All rights reserved. Respiratory organs—Popular works.istockphoto. QP121.(The human body) “In association with Britannica Educational Publishing.R467 2011 612. 60.
Lymphatic Vessels.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. 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 .
Circulation.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. 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 .
The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. The clean air then travels into the deep tissues of the lungs. This book explains the science behind the amazing human respiratory system. and the left lung has 8 to 10. The larynx is a hollow tube connected to the top of the windpipe. It also sheds light on how easily a healthy respiratory system can be damaged. or throat. However. air travels through the trachea. Here. warming. also known as the windpipe. whether by a viral or bacterial infection or through detrimental habits such as smoking. and moistening inhaled air. A thin membranous sac known as the pleura covers the lungs. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. humans could not survive on Earth. Without this ability. After passing through the larynx. eventually reaching the region where gas is exchanged. This structure provides humans with the sense of smell while also filtering. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. or voice box. the air is cleansed and moistened before entering the lungs. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. there are numerous nerves and blood vessels. the centre of the respiratory system. Air that passes through the nose travels to the pharynx. They pump vital oxygen through airways and into the bloodstream every second of every day.7 Introduction 7 he human lungs are amazing feats of nature. the cone-shaped passageway leading from the mouth and nose to the larynx. the most prominent feature of the lung interior are the many small air passages called 11 T . Inside the lungs. The right lung has 10 airway segments. But there are many treatments to keep the airways free and clear.
and tissue. The second blood system in the lungs. humans and other animals do not need to actively think about breathing in order for it to happen. is made up of three separate compartments for blood. but still keeps them separate. which makes exchanging gases easier. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. Lungs also have two distinct blood circulation systems.7 The Respiratory System 7 bronchioles. the oxygenated blood is pumped to the rest of the body. air. through the pulmonary arteries. comprises the network of blood vessels supporting the conducting airways themselves. The act of breathing. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 . is an automatic process. The tissue compartment supports the air and blood compartments and lets them come into close contact. The gas-exchange area. through the pulmonary veins. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs.12 inch) to less than 1 mm (less than 0.04 inch). the pulmonary system. controlled by the brain. Thus. thereby delivering oxygen and other nutrients to organs distant from the lungs. The bronchial circulation is a vital source of nourishment for the lung tissues. The first of these. which look like cells in a honeycomb. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. the region where oxygen is transferred to the blood and carbon dioxide is removed. the bronchial circulation. From the heart. and to the left atrium of the heart. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. which range in diameter from 3 mm (0. The average adult lung has approximately 300 million alveoli. or respiration.
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. 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. The 13 . Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. During exercise. which are located throughout the body. In contrast. others respond to chemical changes in the immediate external environment. These effects trigger an increase in respiration rate. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. This response represents the body’s attempt to prevent toxins from entering the lungs.7 Introduction 7 abdomen. One of the major abdominal muscles involved in breathing is the diaphragm. metabolic rate and acid levels in muscle tissue increase. which functions to move air in and out of the lungs as it contracts and relaxes. In the basic mechanics of breathing. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. during sleep. air moves in and out of the lungs in response to pressure changes. When stimulated. In addition to the types of sensors described above. there also exist sensors that monitor the muscles that control breathing. respectively. these receptors constrict the airways and cause breathing to become fast and shallow. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream.
circulation. cells are unable to function properly. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. Respiration. can cause the brain and the heart to stop functioning. acclimatization. In adults. the small air spaces in the lungs. which can lead to death. even for only a few minutes. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. At high altitudes. but it is assisted by a complex assembly of other muscle groups. The pulmonary alveoli. Without oxygen. in which the body works to more efficiently utilize oxygen in the air. The amount of air that the lungs pump changes dramatically depending on external or internal conditions. during vigorous breathing. The main purpose of respiration is to provide oxygen for the body’s cells. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside.7 The Respiratory System 7 diaphragm is the major muscle that facilitates breathing. an activity that is necessary to supply energy to the cells and the body. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. However. and metabolism all work together. Oxygen is used by cells for the breakdown of nutrients. The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. Oxygen deprivation. is a gradual process. This exchange of gases takes place over an immense surface area. The oxygen that the alveoli transfer to the blood is then circulated to the heart and the body’s other tissues. oxygen is present at lower levels than it is at low altitudes. transfer carbon dioxide from and add oxygen to blood. hiking up during the day and descending down to camp to 14 . People who live at high altitudes adapt to this decrease in oxygen availability.
a condition known as tracheitis. The 15 . Although bacteria sometimes cause pneumonia. which can be particularly dangerous in infants and in the elderly. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. because these individuals are unable to defend against infectious organisms. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. it was a leading cause of death. Before antibiotics were widely available. In the lower respiratory system. If these precautions are not taken.7 Introduction 7 sleep at night. certain viruses and fungi can also cause the disease. many people have their tonsils removed after suffering from chronic tonsillitis. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. Pneumonia also often affects persons with impaired immune systems. Inflammation of respiratory tissues can sometimes be severe and chronic. death is caused by drowning. which can arise as a result of infection. the body’s tissues become deprived of oxygen. pneumonia was a widespread and notoriously deadly disease. as climbers make their way up the mountain. This enables the body to adjust to the decreased availability of oxygen. in which the body circulates additional blood to the lungs. bacteria can cause inflammation of the trachea. as well as bacterial pneumonia. but the blood leaks into the air sacs. In the 18th and 19th centuries. Tuberculosis is another example of a respiratory disease caused by bacteria. which can lead to high-altitude pulmonary edema. For example. Other common upper respiratory conditions include sore throat and pharyngitis. Essentially. and in the first decade of the 21st century.
Influenza is a common. A respiratory disease of major concern in the world today is lung cancer. Some respiratory diseases are inherited. no cause has been identified. blood vessels in the lungs burst. Eventually. For example. chills. in which the collapse of the airways leads to intermittent stoppages in breathing. Infection is accompanied by fever. One example is idiopathic pulmonary fibrosis. which caused between 25 million and 50 million deaths worldwide. snoring is caused by blocked airways.” and thus is used to describe diseases of uncertain origin. seasonal respiratory illness that is caused by viral infection. to form. and the infected person coughs up bright red blood. Lung cancer can arise as a result of a 16 . One of the deadliest influenza pandemics was that of 1918–19. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. which may be associated with obesity. resulting in the formation of cavities in the lungs. This process leads to the eventual breakdown of respiratory tissues. the primary symptom of which is the production of a thick. A severe form of snoring is sleep apnea. which results in progressive shortness of breath until a person can no longer breathe. It is a highly contagious disease too. or large cheese-like masses. Sleep apnea causes affected individuals to awaken periodically through the night. Many respiratory conditions arise from noninfectious causes. The term idiopathic means “of unknown cause. For some diseases of the respiratory system. muscle pains. headaches. Every few decades.7 The Respiratory System 7 tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). One of the best-characterized inherited conditions is cystic fibrosis. a strain of influenza virus gives rise to a pandemic. despite extensive research. and stomach pain. sticky mucus that blocks the airways and the digestive tract.
or work. more than 7 percent of children and 9 percent of adults suffer from asthma. and even cockroaches. Today. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. 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. Construction workers and insulators exposed to asbestos often suffer from asbestosis. Scientists are constantly researching and developing new and different treatments for respiratory ailments. most likely resulting from exposure to air pollution. although tobacco smoking is the primary cause.3 million fatalities each year. factors. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. have been around for years and are readily available. however. or white lung disease. Breathing problems caused by allergies to environmental conditions are fairly common. it was still considered rare. Some respiratory diseases arise as a result of occupational. tobacco smoke. The best-known occupational lung disease is black lung. There is hope for those who suffer from respiratory diseases and disorders. Several vaccines have been developed to prevent illnesses such as influenza. however. Breathing asbestos can also cause the cancerous condition known as mesothelioma. lung cancer is the leading cause of cancer deaths worldwide. In addition to vaccines and antivirals.7 Introduction 7 variety of factors. which affects coal miners who inhale coal dust for many years. Now. 17 . particularly pneumonia and tuberculosis. Nasal decongestants and antihistamines are examples of commonly used remedies. In the early 20th century. Many treatments. resulting in an estimated 1. Doctors first described the symptoms of lung cancer in the mid-19th century.
7 The Respiratory System 7 Lung cancer treatments may consist of surgery. and the consequences of neglecting or damaging that fragile system can be drastic. As this book shows. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. the human respiratory system is a finely tuned feat of engineering. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant. which can identify mutations that render some lung cancers susceptible to certain drugs. Treatment may also be based on the results of genetic screening. A healthy set of lungs is nothing to take for granted. chemotherapy. and radiation. .
and all the airways that branch extensively within the lungs. or respiration. such as the intrapulmonary bronchi. The lower airway system consists of the larynx.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 trachea. Yet. occurring without our having to think about it. as simple as it is for us to inhale and exhale. the bronchioles. is fundamental to survival. Breathing. The respiratory system consists of two divisions: upper airways and lower airways. where its delicate tissues are 19 . and the alveolar ducts. is located in the thorax (or chest). it is otherwise an automatic process. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. the lung. the design of the respiratory systeM The human gas–exchanging organ. the pharynx (or throat). the stem bronchi. supporting this process are a number of complex actions that occur within our bodies. The upper airway system comprises the nose and the paranasal cavities (or sinuses). and though we possess the ability to consciously control the rate of our breathing. These actions encompass not only muscular movements but also cellular and chemical processes. just at the top of the larynx (or voice box). and part of the oral cavity.
7 The Respiratory System 7 The lungs serve as the gas-exchanging organ for the process of respiration. called conducting airways. Inc. protected by the bony and muscular thoracic cage. Atmospheric air is pumped in and out regularly through a system of pipes. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product. carbon dioxide. Encyclopædia Britannica. 20 .
and it protects against the passage into the lungs of potentially infectious foreign agents. such as enabling the sensation of smell.. the heart and the blood vessels). and the intercostal muscles of the chest wall play an essential role by generating. the nasal cavity. In addition to fulfilling a fundamental role in respiration.e. under the control of the central nervous system.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. Morphology of the upper airways The nose. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. The muscles expand and contract the internal space of the thorax. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract. the nasal 21 . The diaphragm. sinuses. which acts as a carrier of gases. the structures of the upper respiratory tract also have other important functions. For respiration. the pumping action on the lung. as the main respiratory muscle. and the circulatory system (i. the collaboration of other organ systems is essential. through which air may be inhaled or exhaled. Other elements fundamental to the process of respiration include the blood. The filtering process is vital to clearing inhaled air of dust and other debris. The Nose The nose is the external protuberance of an internal space. whose bony framework is formed by the ribs and the thoracic vertebrae. is sometimes also considered a part of the upper airways. which pumps blood from the heart to the lungs and the rest of the body. The oral cavity.
The paranasal sinuses are sets of paired single or multiple cavities of variable size. frontal. via the nasolacrimal duct. consists principally of two cell types. which is located in the upper posterior wall of the nasal cavity. and inferior nasal meatuses. the frontal sinus. The sinuses are located in four different skull bones: the maxilla. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. it is also flooding the nasal cavity.7 The Respiratory System 7 septum. 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 duct drains the lacrimal fluid into the nasal cavity. and they reach their final size around age 20. the superior. This structural design 22 . the mucosa of the nose contains mucus-secreting glands and venous plexuses. which is the largest cavity. the ethmoid sinuses. and they serve as resonance chambers for the human voice. and sphenoid bones. they help keep the weight of the skull within reasonable limits. Each canal opens to the face by a nostril and into the pharynx by the choana. middle. Most of their development takes place after birth. they are called the maxillary sinus. On each side. Correspondingly. The passageways thus formed below each ridge are called the superior. ciliated and secreting cells. and inferior turbinate bones (or conchae). The floor of the nasal cavity is formed by the palate. The complex shape of the nasal cavity results from projections of bony ridges. ethmoid. Its top cell layer. from the lateral wall. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also. with the lacrimal apparatus in the corner of the eye. The sinuses have two principal functions: because they are filled with air. which also forms the roof of the oral cavity. Typically. and the sphenoid sinus. the epithelium. middle.
the air is dried and cooled.7 Anatomy and Function of the Human Respiratory System 7 Sagittal view of the human nasal cavity. a process that saves water and energy. Inc. The vestibule. the olfactory organ with its sensory epithelium checks the quality of the inspired air. About two dozen olfactory nerves convey the sensation of smell from the 23 . and warm the inspired air. In the roof of the nose. During expiration through the nose. preparing it for intimate contact with the delicate tissues of the gas-exchange area. reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. Two regions of the nasal cavity have a different lining. They clean. at the entrance of the nose. Encyclopædia Britannica. is lined by skin that bears short thick hairs called vibrissae. moisten.
The upper floor. 24 . In the posterior wall of the Sagittal section of the pharynx. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. Encyclopædia Britannica. the pharynx can be divided into three floors. is primarily a passageway for air and secretions from the nose to the oral pharynx.7 The Respiratory System 7 olfactory cells through the bony roof of the nasal cavity to the central nervous system. The Pharynx For the anatomical description. 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 nasopharynx. Inc.
7 Anatomy and Function of the Human Respiratory System 7 nasopharynx is located a lymphatic organ. The cavity is enclosed by the ribs. which roofs the posterior part of the oral cavity. during the act of swallowing. 25 . controls the traffic of air and food. a cartilaginous. trachea. the pharyngeal tonsil. Morphology of the lower airways The major structures of the lower airways include the larynx. and food from the oral cavity is routed to the esophagus directly behind the larynx. the great arteries bringing blood from the heart out into general circulation. the vertebral column. It is delimited from the nasopharynx by the soft palate. while the lungs themselves receive the air and facilitate the process of gas exchange. and lungs. The lower floor of the pharynx is called the hypopharynx. The lungs reside within the thoracic cavity (chest cavity). it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx. When it is enlarged (as in tonsil hypertrophy). the vessels transporting blood between the heart and the lungs. it may interfere with nasal respiration and alter the resonance pattern of the voice. and the sternum (or breastbone) and is separated from the abdominal cavity (the body’s largest hollow space) by a muscular and membranous partition. The epiglottis. which is the second–largest hollow space of the body. The first two of these provide a canal for the passage of air to the lungs. functions as a lid to the larynx and. leafshaped flap. Its anterior wall is formed by the posterior part of the tongue. Lying directly above the larynx. the diaphragm. The middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx. Also residing within the thoracic cavity is the tracheobronchial tree: the heart.
and the great vessels. most of them minute. and as the organ of phonation. so called because it exudes a thin fluid. when it occurs. or serum. The pleural cavity is the space. as the mediastinal pleura. the mediastinum being the space and the tissues and structures between the two lungs. the two surfaces tend to touch. This portion of the chest membrane is called the parietal pleura. between the parietal and the visceral pleura. the glottis. the heart. where it is called the visceral pleura. the muscles must be anchored to a stabilizing framework. Control is achieved by a number of muscles innervated by the laryngeal nerves. and over part of the esophagus. 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. The membrane continues over the lung. The largest cartilage of the larynx.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. this function can be closely controlled and finely tuned. the thyroid cartilage. 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. The laryngeal skeleton consists of almost a dozen pieces of cartilage. For the precise function of the muscular apparatus. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. As evidenced by trained singers. interconnected by ligaments and membranes. The chest cavity is lined with a serous membrane. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. is made of two plates fused 26 .
The cricoid. to which it is joined in an articulation reinforced by ligaments. 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. has a signet-ring shape. below it is a forward projection. the laryngeal prominence. they are also formed by the free end 27 . they follow its tilting movement. the epiglottis is also attached to the back of the thyroid plate by its stalk. Both of these structures are easily felt through the skin. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. The vocal ligaments are part of a tube. Behind the shieldlike thyroid cartilage.7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. the lumen of the laryngeal tube has an hourglass shape. made of elastic tissue. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. the arytenoid cartilages. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. Because the arytenoid cartilages rest upright on the cricoid plate. the thyroid notch. resembling an organ pipe. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. another large cartilaginous piece of the laryngeal skeleton. which has given this structure the common name of Adam’s apple. The transverse axis of the joint allows a hingelike rotation between the two cartilages. The cricoid is located below the thyroid cartilage. the vocal cords span the laryngeal lumen. 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. Like the true vocal cords. Just above the vocal cords. Viewed frontally.
The practical consequence of 28 . The intrinsic muscles attach to the skeletal components of the larynx itself. This space is called the ventricle of the larynx. Between the vestibular folds and the vocal cords. The right main bronchus has a larger diameter. The intrinsic muscles act directly or indirectly on the shape. The muscular apparatus of the larynx comprises two functionally distinct groups. is oriented more vertically. The Trachea and the Stem Bronchi Below the larynx lies the trachea. the latter can easily be seen from above with the laryngoscope. Because the gap between the vestibular folds is always larger than the gap between the vocal cords. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. one each for the left and right lung. and is shorter than the left main bronchus. the laryngeal space enlarges and forms lateral pockets extending upward. The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. At its lower end. the trachea divides in an inverted Y into the two stem (or main) bronchi. during high-pitched phonation or swallowing) or downward. moving it upward (e. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. length..8 inch) wide. The interior of the trachea is lined by the typical respiratory epithelium. The extrinsic muscles act on the larynx as a whole. The mucosal layer contains mucous glands. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. an instrument designed for visual inspection of the interior of the larynx. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue.7 The Respiratory System 7 of a fibroelastic membrane. and tension of the vocal cords.g.
however. where both functions grade into one another. however. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation.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. 29 . Functionally. the daughter branches may differ greatly in length and diameter. Individual paths. The structure of the stem bronchi closely matches that of the trachea. if the trachea is counted as generation zero. From a morphological point of view. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions. the intrapulmonary airway system can be subdivided into three zones: a proximal. and a transitional zone in between. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. In modeling the human airway tree. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. however. it makes sense to distinguish the relatively thick-walled. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. In irregular dichotomy. largely determines the internal lung structure. a peripheral. it is generally agreed that the airways branch according to the rules of irregular dichotomy. and partly also of the blood vessels penetrating the lung. purely conducting zone. purely gas-exchanging zone. structural design of the airway tree The hierarchy of the dividing airways. may range from 11 to 30 generations.
The epithelium is covered by a layer of low-viscosity fluid. and indeed the mechanism is referred to as the mucociliary escalator. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. 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. Their function is to further warm. This design can be compared to a conveyor belt for particles. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. moisten. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. The last purely conductive airway generations in the lung are the terminal bronchioles. In the alveoli. the alveoli are so densely packed along the airway that an airway wall 30 . the walls of the bronchioles. the bronchi. where they are swallowed. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. the two stem bronchi. Distally.7 The Respiratory System 7 The conducting airways comprise the trachea. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. their height decreasing with the narrowing of the tubes. In larger airways. gain their stability from their structural integration into the gas-exchanging tissues. devoid of cartilage. rhythmic beat directed outward. this fluid layer is topped by a blanket of mucus of high viscosity. within which the cilia exert a synchronized. as does the frequency of goblet cells. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. and the bronchioles. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. After several generations of such respiratory bronchioles.
The right lung represents 56 percent of the total lung volume and is composed of three lobes. while their apexes extend above the first rib. they are connected with the mediastinum at the hilum. and the thymus gland. In the thorax. separated from each other by a deep horizontal and an oblique fissure. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. The left lung. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. the trachea with the stem bronchi. a superior. major blood vessels. and nerves enter or leave the lungs. and the airway consists of alveolar ducts. the two lungs rest with their bases on the diaphragm. smaller in volume because of the asymmetrical position of the heart. The final generations of the airway tree end blindly in the alveolar sacs. Medially. The space between them is filled by the mediastinum. middle. the esophagus. The parietal pleura and the visceral pleura that line the inside 31 .7 Anatomy and Function of the Human Respiratory System 7 proper is missing. Gross Anatomy Together. the lungs occupy most of the intrathoracic space. the lungs Humans have two lung organs. blood and lymphatic vessels. a circumscribed area where airways. In humans each lung is encased in a thin membranous sac called the pleura. has only two lobes separated by an oblique fissure. and inferior lobe. a right and a left. The right and left lungs are slightly unequal in size. which corresponds to a connective tissue space containing the heart.
so the pleural cavity is larger than the lung volume. Encyclopædia Britannica. and diaphragmatic pleurae.7 The Respiratory System 7 Anatomy of the human lungs. thus allowing the lung to increase in volume. the parietal pleura can be subdivided into three portions: mediastinal. Although the hilum is the only place where the lungs are secured to surrounding structures. the recesses are partly opened by the expanding lung. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. costal. are in direct continuity at the hilum. of the thoracic cavities and the lung surface. A thin film of extracellular fluid between the pleurae enables 32 . Depending on the subjacent structures. During inspiration. Inc. respectively. The presence of pleural recesses form a kind of reserve space.
This outer fibrous layer contains. There are 10 segments in the right lung and 8 to 10 segments in the left lung.7 Anatomy and Function of the Human Respiratory System 7 the lungs to move smoothly along the walls of the cavity during breathing. besides lymphatics and nerves. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. Unlike the lobes. These anatomical features are important because pathological processes may be limited to discrete units. 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. and breathing is abolished on this side. depending on the classification. the pulmonary segments. and the surgeon can remove single diseased segments instead of whole lobes. The Bronchi and Bronchioles In the intrapulmonary bronchi. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. Bronchioles are 33 . respiratory movements can be painful. the arterial supply follows the segmental bronchi. Furthermore. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics. the lung immediately collapses owing to its inherent elastic properties. Pulmonary Segments The lung lobes are subdivided into smaller units. If air enters a pleural cavity (pneumothorax). If the serous membranes become inflamed (pleurisy).
conductive airways. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments.7 The Respiratory System 7 small conducting airways ranging in diameter from three to less than one millimetre. The respiratory gases diffuse from air to blood. On average. the frequency of alveolar outpocketings increases rapidly. and tissue. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. The gas-exchange tissue proper is called the pulmonary parenchyma. the whole wall is formed by alveoli. The Gas-Exchange Region The gas-exchange region comprises three compartments: air. and vice versa. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. and non-capillary blood vessels belong to the non-parenchyma. while the supplying structures. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. lymphatics. Whereas air and blood are continuously replenished. until after two to four generations of respiratory bronchioles. blood. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. with a 34 . an adult human lung has about 300 million alveoli. capable of narrowing the airway. The walls of the bronchioles lack cartilage and seromucous glands. Distally. through the 160 square metres (about 1.722 square feet) of internal surface area of the tissue compartment. They are polyhedral structures. The airways are then called alveolar ducts and. in the last generation. which produce secretions. alveolar sacs. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells.
and open on one side. Type II pneumocytes produce a surface-tension-reducing material. alveolar macrophages creep around within the surfactant fluid. Before it is released into the airspaces. Ultimately. It contains connective tissue and interstitial 35 . The alveolar wall. is common to two adjacent alveoli. and their task is to keep the air–blood barrier clean and unobstructed. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. covers the remaining surface. They are large cells. covers between 92 and 95 percent of the gas-exchange surface. a second. called the interalveolar septum. The interalveolar septum is covered on both sides by the alveolar epithelial cells. and a skeleton of connective tissue fibres.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. where they connect to the airway. The type I cells form. the alveolar macrophages are derived from the bone marrow. or cell debris originating from cell damage or normal cell death. squamous cell type. the type I pneumocyte. A thin. partly foreign material that may have reached the alveoli. It contains a dense network of capillaries. together with the endothelial cells. the thin air–blood barrier for gas exchange. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. and their cell bodies abound in granules of various content. the smallest of the blood vessels. These granules are the conspicuous ultrastructural features of this cell type. more cuboidal cell type. the pulmonary surfactant. whereas type II cells are secretory. the type II pneumocyte. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. On top of the epithelium.
If for some reason the delicate fluid balance of the pulmonary tissues is impaired. This pathological condition is called pulmonary edema. to prevent the accumulation of extracellular fluid in the interalveolar septa. an excess of fluid accumulates in the lung tissue and within the airspaces. which seem to be endowed with contractile properties. As a consequence. is carried from the right heart through the pulmonary arteries to the lungs. and Nerves With respect to blood circulation. and proper functioning of the lung is severely jeopardized. the pulmonary arteries.7 The Respiratory System 7 fluid. alternatively. and cells (mainly fibroblasts). Because intravascular pressure determines the arterial wall structure. The connective tissue comprises a system of fibres. After numerous divisions. Blood Vessels. On each side. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. the respiratory gases must diffuse across longer distances. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. The fibroblasts are thought to control capillary blood flow or. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. The oxygenated blood from the capillaries is collected by 36 . the lung is a complex organ. following relatively closely the course of the dividing airway tree. low in oxygen content but laden with carbon dioxide. Lymphatic Vessels. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. amorphous ground substance. are much flimsier than systemic arteries of corresponding size. Blood. which have on average a pressure five times lower than systemic arteries.
Generally. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. They are small vessels and generally do not reach as far into the periphery as the conducting airways. The superficial. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels.7 Anatomy and Function of the Human Respiratory System 7 venules and drained into small veins. however. they end several generations short of the terminal bronchioles. Small bronchial veins exist. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. called bronchomediastinal trunks. With a few exceptions. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. The bronchial arteries originate from the aorta or from an intercostal artery. The interlobular veins then converge on the intersegmental septa. Finally. Within the lung and the mediastinum. originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. 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. Most of their blood is naturally collected by pulmonary veins. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. Lymph drainage 37 .
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
and maintaining posture. Although the diaphragm is the major muscle of breathing. chewing and swallowing. the size of the airway. they also complicate the regulation of breathing. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. 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. 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. In addition. the force of respiratory muscle contraction. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. Intercostal muscles inserting on the ribs. These same muscles are used to perform a number of other functions. such as speaking. such as the airway narrowing that occurs in an asthmatic attack. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. and the extent of muscle shortening. abdominal muscles. Mechanoreceptors monitor the expansion of the lung. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions.7 The Respiratory System 7 swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. 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. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. breathing can be 42 .
com 43 . Shutterstock.7 Control and Mechanics of Breathing 7 Singing demands a strong diaphragm to control breath.
central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. allowing the activity of these physiological systems to be coordinated with respiration. in turn they drive cranial motor neurons. which supply the diaphragm and other thoracic and abdominal muscles. 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. Neurally. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath.
As the activity of the post-inspiratory neurons subsides. This type of breathing. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. which produces lung expansion. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. early inspiratory. Then the cycle begins again. although in upright humans the lower expiratory intercostal muscles 45 . but at a much lower level. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. which occasionally occurs in persons with diseases of the brain stem. Offswitch neurons in the medulla terminate inspiration. and expiratory. After a gap of a few milliseconds. This increase in activity. When the vagus nerves are sectioned or pontine centres are destroyed. offswitch. and gradually declines until the onset of expiratory neuron activity. Mechanically. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. expiratory neurons discharge and inspiratory neurons are strongly inhibited. inspiratory activity is restarted. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. post-inspiratory. breathing is characterized by prolonged inspiratory activity that may last for several minutes. is called apneustic breathing. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity.7 Control and Mechanics of Breathing 7 abruptly. 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. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration.
too much ventilation depresses the partial pressure of carbon dioxide. which restores partial pressures of oxygen and carbon dioxide to their usual levels. There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. Peripheral Chemoreceptors Hypoxia. As expiration proceeds. for example. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. as the demand to breathe increases (for example. and central chemoreceptors in the brain. cheMoreceptors One way in which breathing is controlled is through feedback by chemoreceptors. or the reduction of oxygen supply to tissues to less than physiological levels (produced. During sleep and anesthesia. which leads to a reduction in chemoreceptor activity and a diminution of ventilation.7 The Respiratory System 7 and the abdominal muscles may be active even during quiet breathing. 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. with exercise). Conversely. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). more expiratory intercostal and abdominal muscles contract. 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. Moreover. by a 46 .
responding more to rapid than to slow changes in the partial pressure of carbon dioxide. a branch of the glossopharyngeal nerve. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. Acetylcholine.7 Control and Mechanics of Breathing 7 trip to high altitudes). The amplitude of these fluctuations. The type I cells are arranged in groups and are surrounded by type II cells. stimulates the carotid and aortic bodies. as reflected in the size of carotid body signals. unlike type II cells. Fine sensory nerve fibres are found in juxtaposition to type I cells. The type II cells are generally not believed to have a direct role in chemoreception. the carotid body consists of two different types of cells. which. contain electron-dense vesicles. catecholamines. vasoactive 47 . and the carotid body senses these fluctuations. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls. and neuropeptides such as enkephalins. Microscopically. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. the principal arterial chemoreceptors. may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. 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. In addition to responding to hypoxia. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. 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). This arterial blood parameter rises and falls as air enters and leaves the lungs.
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. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. Even if both the carotid and aortic bodies are removed. 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. Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. inhaling gases that contain carbon dioxide stimulates breathing. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. are located within the vesicles. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. 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. which then act on the sensory nerve.7 The Respiratory System 7 intestinal peptide. and substance P. The aortic bodies located near the arch of the aorta also respond to acute changes in the partial pressure of oxygen. Current thinking places these receptors near the undersurface (ventral part) of the 48 . This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. As the partial pressure of carbon dioxide in arterial blood rises.
Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. because they can help maintain tidal volume and ventilation at normal levels. called spindles. Stimulation of these receptors. Changes in the length of a muscle affect the force it can produce when stimulated. Generally. there is a length at which the force generated is maximal. Receptors. which excites stretch receptors in the airways. These receptors are particularly important when lung function is impaired. 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. 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. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain.7 Control and Mechanics of Breathing 7 medulla. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. Tendon organs. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. 49 . monitor changes in the force produced by muscle contraction. The Hering-Breuer reflex is initiated by lung expansion. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. another receptor in muscles.
and prostaglandins. When lung inflation is prevented. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. during sleep.7 The Respiratory System 7 which send signals to the medulla by the vagus nerve. 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. Stimulation of irritant receptors also causes coughing. however. bradykinin. For example. the reflex allows inspiratory time to be lengthened. accelerating the frequency of breathing. increased levels of oxygen are needed to fuel muscle function. these receptors constrict the airways and cause rapid shallow breathing. during exercise. This in turn leads to fluctuations in breathing patterns. by the vagus nerve. These receptors are supplied. When stimulated. others (the J receptors) by unmyelinated fibres. At the opposite end of the spectrum. may be to defend the lung against noxious material in the atmosphere. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. like the stretch receptors. the body’s metabolic rate slows. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. 50 . shortens inspiratory times as tidal volume (the volume of air inspired) increases. Variations in breathing Variations in breathing result from changes in metabolic demands in the tissues of the body. However. which inhibits the penetration of injurious agents into the bronchial tree. helping to preserve tidal volume. and thus breathing typically becomes lighter. The most important function of these receptors.
which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide. arterial chemoreceptors. Mechanoreceptors.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. and thermal receptors. A number of signals arise during exercise that can augment ventilation. and thermal receptors all work in concert during exercise to enhance ventilation. Sources of these signals include mechanoreceptors in the exercising limbs.com 51 . Shutterstock. because body temperature rises as metabolism increases. thus preserving acid–base homeostasis. the arterial chemoreceptors.
but it may entail unstable feedback regulation of breathing. In slow-wave sleep. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. This rhythmic waxing and waning of breathing. after the physicians who first described it. whereas in rapid eye movement sleep. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. It remains unclear. with intermittent periods of apnea. however. 52 . The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. how these various mechanisms are adjusted to maintain acid–base balance. breathing is diminished but remains regular. Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. Sleep During sleep. is called Cheyne-Stokes breathing.7 The Respiratory System 7 The brain also seems to anticipate changes in the metabolic rate caused by exercise. 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. body metabolism is reduced. During sleep. breathing can become quite erratic. or even apnea (cessation of breathing). The effects on ventilatory pattern vary with sleep stage. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. 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.
the Mechanics of breathing Air moves in and out of the lungs in response to differences in pressure. occurs most commonly in the elderly. undergo phasic changes in their electrical activity synchronous with respiration. in males. however. Because atmospheric pressure remains relatively constant. termed sleep apnea syndrome. and in the obese. portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids. and complaints of excessive daytime drowsiness are common. and the reduced activity of these muscles during sleep may lead to upper airway closure. air is blown from the lungs (expiration).7 Control and Mechanics of Breathing 7 In addition. this intermittent obstruction occurs repeatedly during the night. in the newborn. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. provided the larynx is open. sleep is of poor quality. Because arousal is often associated with the termination of episodes of obstruction. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways. When the air pressure within the alveolar spaces falls below atmospheric pressure. like the tongue and laryngeal adductors. Others. air enters the lungs (inspiration). which increase the likelihood of obstruction. When the air pressure within the alveoli exceeds atmospheric pressure. Many of the upper airway muscles. The condition. flow is determined by how 53 . Snoring and disturbed behaviour during sleep may also occur. In some persons with sleep apnea syndrome. In some individuals. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. have normal upper airway anatomy. leading to severe drops in the levels of blood oxygenation.
A difference in air pressure between atmosphere and lungs is created. less air per unit of volume in the lungs and pressure falls. When the muscles of inspiration relax. forcing air in and out of the lungs. 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. Encyclopædia Britannica. There is. much above or below atmospheric pressure the pressure within the lungs rises or falls. the volume of chest and lungs 54 . and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume. therefore. Each small increment of expansion transiently increases the space enclosing lung air. Inc.7 The Respiratory System 7 The diaphragm contracts and relaxes.
then. its pressure rises above atmospheric pressure. 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. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. A lung is similar to a balloon in that it resists stretch. 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. therefore. This. of the force required to keep the lung distended. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. lung air becomes transiently compressed. thereby allowing the lung to separate from the chest at this particular spot. In summary. the pleural pressure reflects primarily two forces: 55 . 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. resulting in flow of air into or out of the lung and establishment of a new lung volume.7 Control and Mechanics of Breathing 7 decreases. 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. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. 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.
the length of each of which is affected by the other. the force required to keep the lung inflated against its elastic recoil and 2. Because the pleural pressure is below atmospheric pressure. And were it not for the inward traction of the lungs on the chest and diaphragm. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. thereby further raising the diaphragm and causing forceful expiration. When these muscles relax. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. Were it not for the outward traction of the chest on the lungs. 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. the force required to cause airflow in and out of the lung. This additional muscular force is removed on relaxation 56 . During inspiration. which are in turn stretched inward by the pull of the lungs.7 The Respiratory System 7 1. these would collapse. as by a wound or by a surgical incision. the additional retraction of lung returns the system to its equilibrium position. The lung– chest system thus acts as two opposed coiled springs.
Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. The respiratory pump is versatile. 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. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. separated by a film of water.154 cubic inches) per minute in adults. muscular contraction occurs only on inspiration. At total relaxation of the muscles of inspiration and expiration. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. such as pieces of glass. Pressures 57 . capable of increasing its output 25 times. expiration being accomplished “passively” by elastic recoil of the lung.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. 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. During ordinary breathing. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. The volume in these circumstances is known as the residual volume.
istockphoto.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. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. can be raised voluntarily to 400 litres per minute.. normally reaching 30 litres per minute in quiet breathing. © www . The beating of cilia (hairline projections) from cells lining the airways 58 .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).e. Airflow velocity.
500 millilitres. 59 . totaling about 0. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. respectively. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. however.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. 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. Normal lungs. and seven litres. 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. In fact. such adherence occasionally does occur and is one of the dreaded complications of premature births.
At high altitudes or during activities such as deep-sea diving. This process of adaptation is necessary to maintain normal physiological function. 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. The area of the alveolar surface in the adult human is about 160 square metres (1. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. which is needed to support the functions of the body’s various tissues. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and.5 micrometre.CHAPTER3 GAS EXCHANGE AND RESPIRATORY ADAPTATION I nhaled air is rich in oxygen. as well as other organ systems. however. in exchange.722 square feet). Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane. The oxygen is then distributed by the blood to the tissues. transfer carbon dioxide to the alveoli. 60 . adapt to variations in atmospheric pressure. gas exchange Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. about 0. the respiratory system. whereas the carbon dioxide is expelled from the alveoli during exhalation. or ¹/¹00 of the diameter of a human hair. For inhaled oxygen to reach these tissues.
com 61 . Shutterstock.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.
but almost equal quantities of the two gases are involved in metabolism and gas exchange. Respiratory gases also move by diffusion across tissue barriers such as membranes. The performance of the heart and circula- 62 . Convection. 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. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. Local flows can be increased selectively. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring 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. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. In a mixture of gases. or mass flow. The rapidity of circulation is determined by the output of the heart.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. in the flow through skeletal muscles during exercise. as occurs. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. for example. which in turn is responsive to overall body requirements. caused by differing modes of transport in the blood. 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. convection and diffusion. the partial pressure of each gas is directly proportional to its concentration. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood.
Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). transport of oxygen Oxygen is poorly soluble in plasma. The curve representing the content of oxygen in blood at various partial pressures of oxygen. called the oxygen-dissociation curve. 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. important determinants of gas transport. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. These systems are present mainly in the red cells. Not all of the oxygen transported in the blood is transferred to the tissue cells. therefore. plays little role in oxygen exchange but is essential to carbon dioxide exchange. the cell-free. liquid portion of blood. The amount of oxygen 63 . 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. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. a protein contained within red cells.2 ml of oxygen per ml of blood.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. Plasma. so less than 2 percent of oxygen is transported dissolved in plasma. Most oxygen is bound to hemoglobin. In alveoli at sea level. which make up 40 to 50 percent of the blood volume in most mammals.
and the curve is shifted 64 . 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. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. Reductions in normal concentrations of hydrogen ions. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. carbon dioxide. At rest. (Affinity denotes the tendency of molecules of different species to bind to one another. as occurs with anemia or extreme exercise. Because of this decreased affinity.3-DPG decrease the affinity of hemoglobin for oxygen. and 2. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. and 2. and the oxygen-dissociation curve shifts to the right. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. carbon dioxide.3-DPG.) Increases in hydrogen ions. or pH.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. carbon dioxide. including hydrogen ions (which determine the acidity. Conversely. of the blood). Although these substances do not bind to hemoglobin at the oxygen-binding sites.3-DPG result in an increased affinity of hemoglobin for oxygen.3-diphosphoglycerate (2. or 2. This reserve is available to meet increased oxygen demands. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). Hemoglobin binds not only to oxygen but to other substances as well. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. with the binding of oxygen.
Some carbon dioxide binds to blood proteins. about 5 percent. whereas a decrease in temperature shifts the curve to the left (increased affinity). The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. A small portion of carbon dioxide. so that temperature-associated changes in oxygen affinity have little physiological importance. principally hemoglobin. The remainder is found in reversible chemical combinations in red blood cells or plasma. 65 . enhanced release of oxygen). Complete elimination would lead to large changes in acidity between arterial and venous blood. Temperature changes affect the oxygen-dissociation curve similarly. Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. 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. Furthermore. an insufficient time to eliminate all carbon dioxide. transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex. The range of body temperature usually encountered in humans is relatively narrow. An increase in temperature shifts the curve to the right (decreased affinity. remains unchanged and is transported dissolved in blood. as occurs at extreme altitude.7 Gas Exchange and Respiratory Adaptation 7 to the left. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. to form a compound known as carbamate. blood normally remains in the pulmonary capillaries less than a second.
are effective buffering agents. Blood acidity is minimally affected by the released hydrogen ions because blood proteins. Carbonic anhydrase. essentially.7 The Respiratory System 7 Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water.) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. especially hemoglobin. inactivating them. (A buffer solution resists change in acidity by combining with added hydrogen ions and. which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-).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. it combines with water to form carbonic acid (H2CO3 ). a relatively weak acid. As carbon dioxide enters the blood. a protein enzyme present inside the 66 . Shutterstock.
Thus. that is. A reverse sequence of reactions occurs when blood reaches the lung. 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. then transported to the plasma. Because the enzyme is present only inside the red blood cell. while 62 percent exists as bicarbonate in plasma. The bulk of bicarbonate ions is first produced inside the cell. where the partial pressure of carbon dioxide is lower than in the blood. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. 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. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. known as the chloride shift. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. 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. however. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. A few amino sites on hemoglobin are oxylabile. The simultaneous exchange of these two ions. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change 67 . bicarbonate accumulates to a much greater extent within the red cell than in the plasma. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. 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.
most carbon dioxide is transported as bicarbonate or carbamate.7 The Respiratory System 7 or binding. and almost all blood entering the lungs participates in gas exchange. because only free carbon dioxide easily crosses biologic membranes. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 . blood flow through the lung is continuous. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. In health. not all inspired air participates in gas exchange. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. Under ideal circumstances. yet this pool is important. 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. because of the increased size of inspired breaths. 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. In contrast to the cyclic nature of ventilation. Between these two events. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. 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. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs.
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. ventilation– blood flow imbalance. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. A reduction in arterial blood oxygenation is seen with shunting. 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. and limitations of diffusion. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. In shunting. alveoli filled with fluid or inflammatory material). shunting.g. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. Because of the differences in oxygen and carbon dioxide transport. but the level of carbon dioxide in arterial blood is not elevated even 69 .. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. venous blood enters the bloodstream without passing through functioning lung tissue. 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.
Blood leaving an unventilated area of the lung has 70 . This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung. As noted earlier.7 The Respiratory System 7 though the shunted blood contains more carbon dioxide than arterial blood. 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. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. and the composite arterial blood carbon dioxide content remains normal. which is usually achieved without difficulty. When blood perfusing the collapsed. As a result. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. 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. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. the content of carbon dioxide is greater than the normal carbon dioxide content. In contrast. Because the carbon dioxide–dissociation curve is steep and relatively linear. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal.
and an increase in blood partial pressure results in a negligible increase in oxygen content. a plateau is reached at the 71 . the amount of carbon dioxide eliminated is increased. therefore. reaches a plateau at the normal alveolar partial pressure. alveoli become either overventilated or underventilated in relation to their blood flow. 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. however. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. In the healthy area of the lung.7 Gas Exchange and Respiratory Adaptation 7 an oxygen content that is less than the normal content. cannot compensate in terms of greater oxygenation for underventilated alveoli because. 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. 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. which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. in the arterial blood. Overventilated alveoli. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. Thus. The oxygen-dissociation curve. however. and each alveolus receives approximately equal quantities of both. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. Inspired air and blood flow normally are distributed uniformly. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. In alveoli that are overventilated.
There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. 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. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. and increased ventilation will not increase blood oxygen content. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. and decreased time available for exchange due to increased velocity of flow. a reduction in the alveolar partial pressure of oxygen required for diffusion. the greater the reduction in blood oxygenation. which facilitates carbon dioxide exchange. loss of surface area available for diffusion of oxygen. For oxygen. In disease. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. however.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. A variety of processes can interfere with this orderly exchange. 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. Carbon dioxide exchange. these include increased thickness of the alveolar–capillary membrane. 72 .7 The Respiratory System 7 alveolar partial pressure of oxygen. These factors are usually grouped under the broad description of “diffusion limitation.
circulation. whose third phosphate bond can release a quantum of energy to fuel many cell processes. cells set the demand for oxygen uptake and carbon dioxide discharge. The circulation of the blood links the sites of oxygen use and uptake. The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. which set the limit for respiration. through the oxidation of foodstuffs such as glucose. and MetabolisM The interplay of respiration. To recharge the molecule by adding the third phosphate group requires energy derived from 73 . circulation. a molecule with only two phosphate bonds. In antiquity and the medieval period. the heart was regarded as a furnace where the “fire of life” kept the blood boiling. Modern cell biology has unveiled the truth behind the metaphor. In the process. and metabolism is the key to the functioning of the respiratory system as a whole. For gas exchange that takes place in the lungs. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). where.7 Gas Exchange and Respiratory Adaptation 7 interplay of respiration. The precise object of respiration therefore is the supply of oxygen to the mitochondria. the energetic needs of the cells are supplied. the mitochondria. Each cell maintains a set of furnaces. such as the contraction of muscle fibre proteins or the synthesis of protein molecules. 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. ATP is degraded to adenosine diphosphate (ADP). This involves transport of oxygen from the lung to the tissues by means of the circulation of blood.
7 The Respiratory System 7 the breakdown of foodstuffs. and 2. or substrates. It begins with 74 . or fermentation. Oxygen is collected from environmental air. In contrast. which requires oxygen and involves the mitochondria. anaerobic glycolysis. or even the organism. aerobic metabolism. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. For any sustained highlevel cell activity. transferred to blood in the lungs. If oxygen supply is interrupted for a few minutes. the aerobic metabolic pathway is therefore preferable. many cells. or its need for oxygen. Two pathways are available: 1. whereas they usually have a reasonable supply of substrates in stock. and since each cell must produce its own ATP (it cannot be imported). aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. because the cells maintain only a limited store of highenergy phosphates and of oxygen. Because oxidative phosphorylation occurs only in mitochondria. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. which operates in the absence of oxygen. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. will die. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. 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.
As more and more muscle cells become engaged in doing work. which is determined by its content of hemoglobin in the red blood cells. 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.5 micrometre) and the surface area of the barrier. which is achieved by convection or mass flow of air through an ingeniously branched system of airways. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. With exercise this rate can be increased more than 10-fold in a normal healthy individual. sets the demand for oxygen. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. This is accompanied by an increased cardiac output. In the most peripheral airways. At rest. or.7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. Blood also serves as carrier for both respiratory gases: oxygen. and by 75 . It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. and carbon dioxide. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. essentially resulting from a higher heart rate. which is bound to hemoglobin in the red blood cells. but a highly trained athlete may achieve a more than 20-fold increase. transport by blood flow. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. a human consumes about 250 ml of oxygen each minute. the demand for ATP and oxygen increases linearly with work rate. and discharge to the cells. more accurately the metabolic rate of the cells. Metabolism. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue.
with the result that waste products. Muscle can do more work. The limit to oxidative metabolism is therefore set by some features of the respiratory system. such as dogs or horses. based on observations that oxygen consumption rates differ significantly among species. Then. oxygen consumption per unit body mass increases as animals become smaller. 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. a feature called allometric variation. Much has been learned from comparative physiology and morphology. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. from the lung to the mitochondria. the athletic species in nature. mainly lactic acid. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. Furthermore. because of the complexity of the system. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. Consequently. well below interspecies differences. but it is not straightforward. but beyond the aerobic scope they must revert to anaerobic metabolism. 76 . this is called adaptive variation. the aerobic scope can be increased by training in an individual.7 The Respiratory System 7 increased ventilation of the lungs. accumulate and limit the duration of work. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. For example. have an aerobic scope more than twofold greater than that of other animals of the same size.
In training. the mitochondria increase in proportion to the augmented aerobic scope. This difference arises from a phenomenon known as adaptive variation. Shutterstock.7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. the muscle cells make more mitochondria. Mitochondria set the demand for oxygen. 77 . cardiac output is augmented by increasing heart rate.com Within the aerobic scope the adjustments are caused by functional variation. If energy (ATP) needs to be produced at a higher rate. in all types of variation. For example. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system.
But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. however. the blood vessels. such as in training. It appears. and the heart can increase in number. the lung lacks this capacity to adapt. 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.7 The Respiratory System 7 It is thus possible that oxygen consumption is limited at the periphery. both in terms of rate and of the size of the ventricles. the levels of hemoglobin in the blood. or volume to augment their capacity when energy needs increase. beyond which oxidative metabolism cannot be increased by training. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. But. the blood. 78 . whereas the mitochondria. If this proves true. The issue of peripheral versus central limitation is still under debate. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. rate. the structure of the alveoli in the lungs. mainly the heart. 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. at the last step of aerobic metabolism. the lung may well constitute the ultimate limit for the respiratory system. which determines the volume of blood that can be pumped with each stroke. In the case of adaptation to high altitudes. whose capacity to pump blood reaches a limit. In the cases of swimming and diving.
7 Gas Exchange and Respiratory Adaptation 7 High Altitudes Ascent from sea level to high altitude has well-known effects on respiration. which heighten the partial pressure of oxygen at all stages. both in the ambient air and in the alveolar spaces of the lung. whether undertaken deliberately or not. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen. commences from the time of exposure to high altitudes. Barry C. which. This very fall poses the major respiratory challenge to humans at high altitude. Humans and some other mammalian species. such as cattle. Indigenous mountain species such as the At high altitudes. Bishop/National Geographic/Getty Images 79 . hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization.
80 .7 The Respiratory System 7 llama. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. which also shortens the diffusion path of oxygen. thought to enhance oxygen perfusion of the lung apices. the carotid bodies enlarge but become less sensitive to the lack of oxygen. on the other hand. the tissues develop more blood vessels. and. Diffusion of oxygen across the alveolar walls into the blood is facilitated. As the oxygen deprivation persists. which takes the form of deeper breathing rather than a faster rate at rest. 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. In addition. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. as capillary density is increased. from the alveolar spaces in the lung to the mitochondria in the cells. With a prolonged stay at altitude. where oxygen is needed for the ultimate biochemical expression of respiration. the carotid bodies. which increases the amount of oxygen transported to the tissues. attached to the division of the carotid arteries on either side of the neck. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. such as 2. 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.3DPG. the size of muscle fibres decreases. exhibit an adaptation that is heritable and has a genetic basis.
Swimming and Diving Fluid is not a natural medium for sustaining human life after the fetal stage. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. In contrast to acclimatized humans. including humans. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the 81 . or benign tumour. This disease is characterized by greater levels of hemoglobin. After living many years at high altitude. these indigenous. after the Peruvian physician who first described it. Human respiration requires ventilation with air. sometimes called Monge disease.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. A chemodectoma. Their hemoglobin has a high oxygen affinity. 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. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. They do not develop small muscular blood vessels or an increased blood pressure in the lung. all vertebrates. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. alpaca. exhibit a set of responses that may be called a “diving reflex. and their carotid bodies remain small. Nevertheless.7 Gas Exchange and Respiratory Adaptation 7 Indigenous mountain animals like the llama. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude. 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. Other physiological changes are also observed.
however. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. as sometimes happens in snorkeling.7 The Respiratory System 7 same time that a diver is breathing from an independent gas supply. 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. But this apparent advantage introduces additional hazards. which is 82 . Hyperventilation can be dangerous. The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. but it cannot provide an equivalent increase in oxygen. Hyperventilation. and this danger is greatly increased if the swimmer descends to depth. many of them unique in human physiology. and consciousness remains unimpaired. the absolute pressure. 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. Two factors are involved. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath. At the depth of a diver. When the accumulated carbon dioxide at last forces the swimmer to return to the surface. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. Most hazards result from the environmental pressure of water. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. Unconsciousness may then occur in or under the water.
The increased work of breathing.7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. rather than cardiac or muscular performance. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. acting at any depth. 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. the blood and tissues of the diver. and the consequences of the uptake of respiratory gases into. the increased density of the respiratory gases. More commonly. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. the levels of inspired oxygen are 83 . but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). This may be compounded by an increased inspiratory content of carbon dioxide. is the vertical hydrostatic pressure gradient across the body. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. The other factor. and their subsequent elimination from. is one factor. often with the formation of bubbles. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. 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. Hypoxia may result from failure of the gas supply and may occur without warning. is the limiting factor for hard physical work underwater. Alveolar oxygen levels can also be disturbed in diving.
and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. At a partial pressure greater than 1.5 bar. 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. Oxygen in excess can be a poison. 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. provides a greater respiratory advantage for deep diving. like an anesthetic. has the additional advantage of providing a breathing gas of lesser density.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. it may cause the rapid onset of convulsions. At the extreme depths now attainable by humans— some 500 metres (1. High values of end-tidal carbon dioxide with 84 . The use of hydrogen.5 bar (“surface equivalent value” = 150 percent).2 and 0. which in a mixture with less than 4 percent oxygen is noncombustible.640 feet) in the sea and more than 680 metres (2.7 The Respiratory System 7 increased. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. approximately in proportion to the reciprocal of the square root of the increasing gas density. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. In mixed-gas diving. inspired oxygen is therefore maintained at a partial pressure somewhere between 0.
a condition that. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. the expanding gas may rupture alveolar septa and escape into interstitial spaces. And whatever the orientation of the diver in the water. in which case more blood will be shifted into the thorax. if it occurs underwater. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). Unless vented. This is a major cause of death among divers. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. possibly extending into the pericardium or into the neck. The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. places the diver at great risk. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. Failure to exhale 85 . resulting in less intrathoracic blood volume. The concept of a hydrostatic balance point within the chest.7 Gas Exchange and Respiratory Adaptation 7 only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. which represents the net effect of the external pressures and the effects of chest buoyancy. has proved useful in designing underwater breathing apparatuses. or it may be effectively greater. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. More seriously. Also.
even from depths as shallow as 2 metres (6. 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.6 feet). can result in a sometimes life-threatening condition known as decompression sickness. 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. Inadequacy of diver decompression. 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. 86 .7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.
However.CHAPTER4 INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM I nfectious diseases are among the most common conditions affecting the human respiratory system. and tonsillitis. requiring patient hospitalization. whereas lower respiratory infections include laryngitis. sinusitis. resulting in patient isolation. In most cases. and tuberculosis. pharyngitis. 87 . and any condition of the bronchi and lungs. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. Legionnaire disease. Examples of severe lower respiratory infections include croup. tracheitis. and molds. various types of pneumonia. Some conditions can cause extensive lung damage. bacteria. however. infectious diseases. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. These diseases may be caused by a variety of agents. as considered here. with this division occurring at the anatomical level of the larynx. and may be highly contagious. upper respiratory infections include the common cold. including viruses. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues. can be effectively treated with prescription antimicrobial drugs. whether of the upper or lower respiratory tract. Thus.
People can carry the virus and communicate it without experiencing any of the symptoms themselves. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract. not from a cold environment. Incubation is short. and the 88 . with little or no medication. and tonsils are frequently the site of both acute and chronic infections.7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses. Some of these infections may resolve on their own. The feeling was originally believed to have a cause-and-effect relationship with the disease. chilled wet feet. In other cases. The viruses start spreading from an infected person before the symptoms appear. The cold is caught from exposure to infected people. are the most frequent cause. and may cause secondary infections in the eyes or middle ears. usually one to four days. pharynx. More than 200 agents can cause symptoms of the common cold. 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. however. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. sometimes spreads to the lower respiratory structures. influenza. an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. but this is now known to be incorrect. or drafts. respiratory syncytial viruses. Rhinoviruses. including parainfluenza. however.
its activities irritate the nose’s cells. There is usually no fever. and minor epidemics commonly occur throughout the winter. There is no effective antiviral agent available for the common 89 . inflammation of the nose (rhinitis). The incidence of colds peaks during the autumn. It may result from the greater amount of time spent indoors. and nasal discharge. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. Symptoms may include sneezing.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. Young children can contract between three and eight colds a year. but the reason for this incidence is unknown. chills. The usual duration of the illness is about five to seven days. headaches. sore throat. Diagnosis of a cold is usually made by medical history alone. yellow-green fluid that is full of the debris of dead cells. usually coming into contact with the infectious agents in day care centres or preschools. thereby setting up sneezing. The nasal discharge is the first warning that one has caught a cold. fatigue. Cold symptoms vary from person to person. If the virus penetrates more deeply into the upper respiratory tract. the clear fluid often changing to a thick. Symptoms abate as the host’s defenses increase. which increases the likelihood of close contact with those persons carrying cold viruses. but in the individual the same symptoms tend to recur in succeeding bouts of infection. a second method of expelling the virus. but it is possible to take a culture for viruses. Coughing can be dry or produce amounts of mucus. but lingering cough and postnasal discharge may persist for two weeks or more. Once a virus becomes established on the respiratory surface of the nose. This fluid acts to dilute the virus and clear it from the nose. The sensory organs in the nose are stung by the inflammatory reaction.
7 The Respiratory System 7 Usually. Shutterstock. and nasal discharge. fatigue. sore throat. rhinitis. headaches. but it can comprise sneezing. chills. the common cold does not involve a fever.com 90 .
mycoplasmas. fever. which typically subside after one week. and the tonsils may secrete pus and become swollen. Inflammation usually involves the nasopharynx. In many studies. Therapy consists of treating the symptoms: relieving aches. 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. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. the throat reddens. A sore throat may be a symptom of influenza or of other respiratory infections. as are antiseptic gargles. and parasites and by recognized diseases of uncertain causes. or a reaction to certain drugs. In treating nonviral sore throat. soft palate. viruses. For a viral sore throat. and tonsils. treatment is aimed at relieving symptoms. 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). 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. Pharyngitis Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. antibiotics are often effective. The illness can be caused by bacteria.7 Infectious Diseases of the Respiratory System 7 cold. Generally. fungi. and nasal congestion. Infection by 91 . uvula.
extremely sore throat that is felt during swallowing. swelling of lymph nodes. headache. Within approximately three days the fever leaves. is instituted.7 The Respiratory System 7 Streptococcus bacteria may be a complication arising from a common cold. syphilis. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. Chronic cases caused by irritants in the environment or by 92 . Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. A number of other infectious diseases may cause pharyngitis. including tuberculosis. and a slight fever. and the cause of pharyngeal inflammation can be determined by throat culture. Lymphatic tissue in the pharynx may also become involved. usually with penicillin. appropriate antibiotic therapy. nausea. however. Viral pharyngitis infections also occur. 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 irritability. sometimes in children there are abdominal pain. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. and meningitis. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. They cause fever. Diagnosis is established by a detailed medical history and by physical examination. a pustulant fluid on the tonsils or discharged from the mouth. diphtheria. headache. requiring treatment with antibiotics. Purulent (pus-producing) sinusitis can occur. If a diagnosis of streptococcal infection is established by culture. and sore throat that last for 4 to 14 days. but the other symptoms may persist for another two to three days.
and fever following previous upper respiratory viral illness. and many other penicillin-sensitive anaerobes. If the infection persists. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. Chronic sinusitis may follow repeated or neglected attacks of acute sinusitis. the pus localized in any individual sinus may have to be removed by means of a minor surgical procedure known as lavage. nasal discharge. Common symptoms include facial pain. Streptococcus pyogenes. Streptococcus pneumoniae. The organisms usually involved are Haemophilus influenzae. When ciliary function is damaged. including surgery. Under normal conditions. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. It may also be caused by allergy to agents 93 . Staphylococcus aureus. On physical examination. The origin of acute sinus infection is much like that of ear infection. persons with sinusitis are usually found to have an elevation in body temperature. and sinus tenderness.7 Infectious Diseases of the Respiratory System 7 impaired immune systems may require more extended treatment. headache. but the adjacent mouth and nose have a varied bacterial flora. keeping the sinuses clean. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. infection can be established. Following a common cold. 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. Normally the middle ear and the sinuses are sterile. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. very small hairs called cilia move mucus along the lining of the nose and respiratory tract.
loss of smell.7 The Respiratory System 7 in the environment. The symptoms of chronic sinusitis are a tendency to colds. The infection lasts about five days. obstructed breathing. with or without heart involvement. resulting in a peritonsillar abscess. Repeated acute infections may cause chronic inflammation of the tonsils. and enlarged lymph nodes on both sides of the neck. The treatment includes bed rest until the fever has subsided. Tonsillitis Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. trachea. In severe cases endoscopic surgery may be necessary to remove obstructions. and sometimes headache. and warm throat irrigations or gargles with a mild antiseptic solution. repeated or persistent sore throat. The infection may extend upward into the nose. difficulty in swallowing. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. fever. Locally. and ears or downward into the larynx. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. such as fungi or pollen. isolation to protect others from the infection. The 94 . sinuses. and swollen lymph nodes in the neck. malaise. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. evidenced by tonsillar enlargement. and bronchi. If antibiotic therapy or repeated lavage do not alleviate the condition. Pain is not a feature of chronic sinusitis. usually hemolytic streptococci or viruses. virulent bacteria may spread from the infected tonsil to the adjoining tissues. purulent nasal discharge. The symptoms are sore throat.
involving long-term antimicrobial therapy. pneumonia. with a grayish membrane that wipes off readily. Likewise. Nonbacterial agents such as chlorine gas. or syphilitic. It becomes swollen and filled with blood. Laryngitis Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. whitish. in trench mouth. In diphtheria the tonsils are covered with a thick. and contains many 95 . can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. and trench mouth may also produce acute tonsillitis. tuberculous. Laryngitis is classified as simple. is associated with a high rate of death in infants and the elderly. For example. diphtheritic. diphtheria. which is a major cause of lung disease globally. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. the infectious disease tuberculosis. lower respiratory systeM infections Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. Usually the mucous membrane lining the larynx is the site of prime infection. Simple laryngitis is usually associated with the common cold or similar infections. steam. adherent membrane.7 Infectious Diseases of the Respiratory System 7 treatment in this case is surgical removal (tonsillectomy). in order to prevent potentially disabling damage to lung tissue. Thus. or sulfur dioxide can also cause severe inflammation. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. secretes a thick mucous substance. Scarlet fever.
leaving ulcers on the surface. becomes swollen and infected by influenza viruses. which closes the larynx during swallowing. alcoholism. A similar type of membrane covering can occur in streptococcal infections. When looser portions of this false membrane become dislodged from part of the larynx. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. As the disease advances to the third stage. The scars can distort the larynx. or overuse of the vocal cords. tissue destruction is followed by healing and scar formation. Chronic laryngitis is produced by excessive smoking. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. In the second stage of syphilis. It may cause a membrane of white blood cells. small lumps of tissue that project from the surface. Most conditions that affect the trachea are bacterial or 96 . and suffocation may result. and diseased skin cells to attach to and infiltrate the surface mucous membrane. sores or mucous patches can form. Syphilitic laryngitis is one of the many complications of syphilis. Tubercular nodule-like growths are formed in the larynx tissue.7 The Respiratory System 7 inflammatory cells. When the epiglottis. The mucous membrane becomes dry and covered with polyps. the larynx can become obstructed. fibrin (blood clotting protein). shorten the vocal cords. and produce a permanent hoarseness of the voice. There may be eventual destruction of the epiglottis and laryngeal cartilage. The bacteria die after infecting the tissue. they may consolidate at the vocal cords and cause an obstruction there. Tracheitis Tracheitis is an inflammation and infection of the trachea. The wall of the larynx may thicken and become inflamed.
Blood vessels increase in number. Neisseria organisms. Diphtheria. Irritants such as heavy smoking and alcoholism may invite infections. pustules and ulcers. The infections produce fever. and small polyplike formations occasionally grow. Generally. fatigue. sulfur dioxide.7 Infectious Diseases of the Respiratory System 7 viral infections. they do not cause significant damage to the tissue unless they become chronic. although irritants like chlorine gas. hemorrhages. streptococci. Common bacterial causes of acute infections are pneumococci. such as those that occur on the external skin. Syphilis forms lesions that erode the 97 . and staphylococci. Infections may last for a week or two and then pass. Chronic infections recur over a number of years and cause progressive degeneration of tissue. In smallpox. tuberculosis. and degeneration of the tracheal tissue can occur. smallpox. and swelling of the mucous membrane lining the trachea. Intense blood congestion. Degenerated tissue is eventually replaced by a fibrous scar tissue. and syphilis all afflict the trachea. The mucous glands may become swollen. form in the mucous membrane. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. but the trachea may also be attacked. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. Diphtheria usually involves the upper mouth and throat. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. Acute infections occur suddenly and usually subside quickly. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. and the walls thicken because of an increase in elastic and muscle fibres. The walls of the trachea during chronic infection contain an excess of white blood cells. Typhoid causes swelling and ulceration in the lymph tissue.
Croup Croup is an acute respiratory illness of young children that is characterized by a harsh cough. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. is a more serious condition that is often caused by Haemophilus influenzae type B. the onset of viral croup is preceded by the symptoms of the common cold for several days. and can cause thickening and stiffening of the spaces between the cartilage. hospitalization may be necessary. with high fever and breathing difficulties. spasms of the laryngeal muscles. Viral infections are the most common cause of croup. In some cases. making it necessary for the patient to sit and lean 98 . Epinephrine and corticosteroids have also been used to reduce swelling of the airway. Bacterial croup.7 The Respiratory System 7 tissue. and they strike most frequently in late fall and winter. the most frequent being those with the parainfluenza and influenza viruses. hoarseness. Some cases result from allergy or physical irritation of these tissues. In cases of severe airway obstruction. It is characterized by marked swelling of the epiglottis. there is obstruction at the opening of the trachea. Generally. also called epiglottitis. Such infections are most prevalent among children younger than age three. The symptoms are caused by inflammation of the laryngeal membranes. inflammation occurs around the bronchial tree. The onset is usually abrupt. 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. or inflammation around the trachea. and difficult breathing. It is most often caused by an infection of the airway in the region of the larynx and trachea.
through which air passes into the lungs. and measles. 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. Infectious Bronchitis Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). preferably by inserting a tube down the windpipe. 99 . Epiglottitis generally strikes children between ages three and seven. Patients are given antibiotics. which generally relieve the inflammation within 24 to 72 hours. or organic solvents. however. It is most frequently caused by viruses responsible for upper respiratory infections. An artificial airway must be opened. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. Therefore. organisms do enter the airways and initiate a sudden and rapid attack. In addition. The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. particularly in people who have underlying chronic lung disease. Children with epiglottitis require prompt medical attention. Acute bronchitis can also be caused by bacteria such as Streptococcus. Under certain circumstances. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. ammonia. it is often part of the common cold and is a common sequel to influenza. whooping cough. resulting usually in a relatively brief disease called acute infectious bronchitis. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids.7 Infectious Diseases of the Respiratory System 7 forward to maximize the airflow. Under ordinary circumstances. influenzae.
Another form of bronchitis. particularly in children between ages one and two. with complete healing in all but a very small percentage of cases. which results in protracted and often permanent damage to the bronchial mucosa. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. In addition to patients acutely exposed to gases. 100 . Bronchiolitis Bronchiolitis refers to inflammation of the small airways. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal. In some cases the inflammation may be severe enough to threaten life. bronchodilators. acute exacerbations of infection are associated with further damage to small airways. but it normally clears spontaneously. or this may develop slowly over time. This pattern of occurrence has only recently been recognized. though there is little doubt that in most patients with chronic bronchitis. an acute bronchiolitis episode is followed by a chronic obliterative condition. in whom such a syndrome may follow the acute exposure. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. discussed in a later chapter. is a long-standing. Steam inhalation.7 The Respiratory System 7 Treatment of acute bronchitis is largely symptomatic and of limited benefit. called chronic bronchitis. In adults. Bronchiolitis probably occurs to some extent in acute viral disorders. In isolated cases. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability. repetitive condition. and expectorants will usually relieve the symptoms. and particularly in infections with respiratory syncytial virus.
but a short cough and progressive shortness of breath may not be evident for hours. after blasting underground. A chest radiograph shows patchy inflammatory change. which may occur from inhaling gas in silos. An inflammation around the small airways. is characteristically not followed by acute symptoms. or in fires involving plastic materials. 101 . 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. These develop some hours later. Symptomatic recovery may mask incomplete resolution of the inflammation. when the victim develops a short cough and progressive shortness of breath. known as a respiratory bronchiolitis. and the lesion is an acute bronchiolitis. is believed to be the earliest change that occurs in the lung in cigarette smokers. Monty Rakusen/Cultura/Getty Images Exposure to oxides of nitrogen.
and it is generally more frequent during the colder months of the year. chills. 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. also known simply as the flu (or grippe). though the highest incidence of the disease is among children and young adults. In three to four days the temperature begins to fall. is an acute viral infection of the upper or lower respiratory tract that is marked by fever.7 The Respiratory System 7 although it does not lead to symptoms of disease at that stage. and trachea. and a generalized feeling of weakness and pain in the muscles. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. with sudden and distinct chills. often accompanied by irritation or a sense of rawness in the throat. and the person begins to recover. by such means as inhalation of infected droplets resulting from coughing and sneezing. The temperature rises rapidly to 38–40 °C (101–104 °F). As the virus particles gain entrance to the body. The inflammation is probably reversible if smoking is discontinued. The flu may affect individuals of all ages. Symptoms associated with respiratory tract 102 . fatigue. together with varying degrees of soreness in the head and abdomen. and muscle aches. Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. Influenza Influenza. after which the onset of symptoms is abrupt. bronchial tubes. A diffuse headache and severe muscular aches throughout the body are experienced. The incubation period of the disease is one to two days.
A newer category of drugs. usually among older people already weakened by other debilitating disorders. and is caused in most of those cases by complications such as pneumonia or bronchitis. the neuraminidase inhibitors. However. was introduced in the late 1990s.7 Infectious Diseases of the Respiratory System 7 infection. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. become more prominent and may be accompanied by lingering feelings of weakness. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). and yearly vaccination may be recommended. such as coughing and nasal discharge. a very serious illness. In order to prevent humaninfecting bird flu viruses from mutating into more 103 . Protection from one vaccination seldom lasts more than a year. Death may occur. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. These viruses are produced in chick embryos and rendered noninfective. particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. thereby reducing their effectiveness. 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. and the use of analgesics to control fever. Other than this. as treatment of viral infections with aspirin is associated with Reye syndrome. ingestion of fluids. these drugs inhibit influenza A. It is recommended that children and teenagers with the flu not be given aspirin. as well as a strain of virus known as influenza type B. routine immunization in healthy people is also recommended. the standard treatment remains bed rest. However. viral resistance to these agents has been observed.
Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. and decreases the spread of the virus through the body. Oseltamivir can be given orally. Inc. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses.S.7 The Respiratory System 7 dangerous subtypes. Zanamivir is given by inhalation only.based pharmaceutical company Hoffman–La Roche. There is evidence that the most common subtype of influenza type A virus. increases the formation of viral aggregates. known as H1N1. a glycoprotein on the surface of influenza viruses. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. has developed resistance to oseltamivir. 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 (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. increases the formation of viral aggregates. If taken within 30 hours of 104 . the drug decreases the release of virus from infected cells. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. Oseltamivir is effective when administered within two days of symptom onset. Through the inhibition of neuraminidase. zanamivir decreases the release of virus from infected cells. and decreases the spread of the virus through the body.S. Oseltamivir is marketed as Tamiflu by the U. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks.
or “whoop. zanamivir can shorten the duration of the illness.” The coughing ends with the expulsion of clear. Whooping Cough Whooping cough. is an acute. isolated and coloured with Gram stain. the causative agent of whooping cough. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. when taken once daily for 10 to 28 days. highly communicable respiratory disease. sticky mucus and often with vomiting. Whooping cough is caused by the bacterium Bordatella pertussis. or pertussis. Bordetella pertussis.7 Infectious Diseases of the Respiratory System 7 the onset of influenza. can prevent influenza infection in some adults and children. Zanamivir. Centers for Disease Control and Prevention (CDC) (Image Number: 2121) 105 .
with bulging eyes. and a low-grade fever. and convalescent—which together last six to eight weeks. with a short dry cough that is worse at night. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. It was first called the Bordet-Gengou bacillus. paroxysmal. In the paroxysmal state. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. In 1906 at the Pasteur Institute. and be dazed and apathetic. it confers active immunity against whooping cough to children. Whooping cough is worldwide in distribution and among the most acute infections of children. slowed or stopped breathing. About 100 years later. and occasionally convulsions and indications of brain damage.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. and pertussis) vaccine. Beginning its onset after an incubation period of approximately one week. there is a repetitive series of coughs that are exhausting and often result in vomiting. the illness progresses through three stages—catarrhal. undoubtedly it had existed for a long time before that. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. The disease was first adequately described in 1578. tetanus. but the periods between coughing paroxysms are comfortable. ear infections. and still later Bordetella pertussis. variable in duration but commonly lasting four to six weeks. Now included in the DPT (diphtheria. Immunization is routinely begun at two months of age and requires five shots for maximum 106 . the name pertussis (Latin: “intensive cough”) was introduced in England. Complications of whooping cough include pneumonia. The infected person may appear blue. red eyes. later Haemophilus pertussis. Catarrhal symptoms are those of a cold. During the convalescent stage there is gradual recovery.
Strict regulations followed concerning 107 . pigeons. Later vaccinations are in any case thought to be unnecessary. ducks. especially if they have been vaccinated in infancy. and another booster is given when the child is between four and six years old. attributed to contact with imported parrots. Psittacosis Psittacosis. occurred in 12 countries of Europe and America. when severe outbreaks. Sedatives may be administered to induce rest and sleep. The association between the human disease and sick parrots was first recognized in Europe in 1879. an antibiotic that may help to shorten the duration of illness and the period of communicability. and geese are the principal sources of human infection. and the United States. also known as ornithosis (or parrot fever). turkeys.7 Infectious Diseases of the Respiratory System 7 protection. because the disease is much less severe when it occurs in older children. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. England. Treatment includes erythromycin. The infection has been found in about 70 different species of birds. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. parrots and parakeets (family Psittacidae. from which the disease is named). the causative agent was revealed. although a thorough study of the disease was not made until 1929– 30. During the investigations conducted in Germany. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. and sometimes the use of an oxygen tent is required to ease breathing. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells.
thus inviting secondary pneumonia caused by bacteria. because of impaired immunity. but it usually occurs in hospitalized persons who. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. the case fatality rate was approximately 20 percent. In humans psittacosis may cause high fever and pneumonia. viruses more commonly play a part in weakening the lung. and an elevated respiratory rate. Other symptoms include chills. and convalescence often is protracted. The typical duration of the disease is two to three weeks. inhalation of foreign particles. weakness. Pneumonia Pneumonia is an inflammation and solidification of the lung tissue as a result of infection. Fungal pneumonia can develop very rapidly and may be fatal. Infected turkeys. Psittacosis usually causes only mild symptoms of illness in birds. ducks. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. but penicillin and the tetracycline drugs reduced this figure almost to zero. Although viral pneumonia does occur. have reduced resistance to 108 . Many organisms. or irradiation. in particular species of Streptococcus and Mycoplasma. head and body aches.7 The Respiratory System 7 importation of psittacine birds. can cause pneumonia. Before modern antibiotic drugs were available. including viruses and fungi. but in humans it can be fatal if untreated. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. but the most common causes are bacteria. or geese have caused many cases among poultry handlers or workers in processing plants.
Contaminated dusts.g. when inhaled by previously healthy individuals. Sputum discharge may contain flecks of blood. In some cases..7 Infectious Diseases of the Respiratory System 7 infection. Bacterial Pneumonia Streptococcal pneumonia. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. and recovery generally occurs in a few weeks. The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the 109 . humidifiers. Treatment is with specific antibiotics and supportive care. and animal excreta or to chemical or physical injury (e. caused by Streptococcus pneumoniae. is the single most common form of pneumonia. particularly in elderly people and young children. can sometimes cause fungal lung diseases. Pneumonia can also occur as a hypersensitivity. coughing becomes the major symptom. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing. or allergic response. smoke inhalation). These fluids provide an environment in which the bacteria flourish. cough. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. As the disease progresses. to agents such as mold. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract. especially in hospitalized patients. the illness may become very severe. and difficulty in breathing. and it is sometimes fatal. chest pain. however.
Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. or institutions. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. caused by Mycoplasma pneumoniae. an atypical infectious form. parainfluenza. small neighbourhoods. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. Most outbreaks of this disease are confined to families. 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. and psittacosis. and influenza viruses. caused by Legionella pneumophilia. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. usually affects children and young adults. few cases beyond age 50 are seen. causing bleeding into the air spaces. which leads to the further release of pneumolysin. Another bacterium. but it does sometimes inflame the bronchi and alveoli. it does not invade the deeper tissues—muscle fibres. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. Klebsiella pneumoniae.7 The Respiratory System 7 lungs. Usually the organism does not invade the membrane that surrounds the lungs. Symptoms of 110 . although it has little ability to infect the lungs of healthy persons. M. although epidemics can occur. Mycoplasmal pneumonia. or nerves. Other bacterial pneumonias include Legionnaire disease. an extremely small organism. elastic fibres.
Diagnosis is established by physical examination and chest X-rays. usually followed by respiratory congestion and cough. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. all of which contain the fungus Actinomyces. A more insidious form of hypersensitivity pneumonia is 111 . and low-grade fever. maple logs. or other chronic diseases. old sheds or barns. and wood pulp may cause similar illnesses. and air-conditioning ducts. and skin testing is included in the initial examination of patients with lung problems. In addition. parakeets. the prognosis is excellent. particularly if the patient was recently exposed to excavations. Nonbacterial pneumonia is treated primarily with supportive care. Other fungi found in barley. Initially. muscle pain. or dust storms. Tuberculosis should always be considered a possibility in any patient with pneumonia. decreased appetite. pigeons. These pneumonias may occur following exposure to moldy hay or sugarcane. and doves may develop manifestations of hypersensitivity pneumonia. shortness of breath.7 Infectious Diseases of the Respiratory System 7 these pneumonias include runny nose. headache. AIDS. these patients experience fever with chills. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. and malaise. all of which may subside in a day if there is no further exposure. cough. people exposed to rats. room humidifiers. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. gerbils. In general. backyard swimming pools.
Treatment consists of removing the patient from the offending environment. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. physical examination. Infections with fungi such as 112 .7 The Respiratory System 7 associated with persistent malaise. Oil that is being swallowed may be breathed into the respiratory tract. known as lipoid pneumonia. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. less often. Scar tissue forms as a result of the presence of the oil. fever. and cough. weight loss. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. bed rest. it may come from the body itself when the lung is physically injured. This type of disease. for example. Pneumonia in Immunocompromised Persons For some years prior to 1980. Ordinarily no treatment is necessary. it had been known that if the immune system was compromised by immunosuppressive drugs (given. Diagnosis is established by medical history. before organ transplantation to reduce the rate of rejection). occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. capable of causing invasive pneumonic lesions in the setting of reduced immunity. and supportive care.) Recovery is usual unless too great an area of lung tissue is involved. are difficult to treat. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. and specific laboratory tests. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. Such infections are a major cause of illness in these patients. or. and may prove fatal.
Although healthy individuals can contract Legionnaire disease. shortness of breath. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L.7 Infectious Diseases of the Respiratory System 7 Candida also occur. The largest known outbreak of Legionnaire disease. Spain. the exact source of outbreaks is often difficult to determine. and abdominal distress are common. often accompanied by chills. as is water at construction sites. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. at a Philadelphia hotel where 182 Legionnaires contracted the disease. 29 of them fatally.S. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. followed by high fever. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. in 2001. the first symptoms of Legionnaire disease are general malaise and headache. Legionnaire Disease Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. Coughing. pleurisy-like pain. a U. Potable water and drainage systems are suspect. 113 . occurred in Murcia. pneumophila in droplets into the surrounding atmosphere. military veterans’ organization. but not uniformly. and occasionally some mental confusion is present. Although it is fairly well documented that the disease is rarely spread through person-to-person contact. 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. Typically. confirmed in more than 300 people.
Mycobacterium tuberculosis. Tuberculosis Tuberculosis is an infectious disease that is caused by the tubercle bacillus. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. L. headache. the bacillus spreads slowly and widely in the lungs. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. Blood vessels also can be eroded by the advancing disease. and death. this cycle of infection can lead to severe pneumonia. the macrophage dies and bursts open. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. “consumption. Treatment for Legionnaire disease is with antibiotics. represents a milder form of Legionella infection. causing the infected person to cough up bright red blood. Pontiac fever. coma. In most forms of the disease. Eventually. During the 18th and 19th centuries. Indeed. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis. In some cases. However. L. at which time improved health and hygiene brought about a steady decline in its mortality rates. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. pneumophila enters the lungs.” as it was then known. pneumophila.7 The Respiratory System 7 Once in the body. Since the 114 . an influenza-like illness characterized by fever. and muscle pain.
but in areas with poor hygiene standards. the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 . in less-developed countries where population is dense and hygienic standards poor. In addition. tuberculosis remains a major fatal disease. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. 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. it continues to be a fatal disease continually complicated by drug-resistant strains. Today.7 Infectious Diseases of the Respiratory System 7 Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries. antibiotic drugs have reduced the span of treatment to months instead of years. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. Fox Photos/Hulton Archive/Getty Images 1940s.
A skin test taken at any later time may reveal the earlier infection and the immunity. Minute droplets ejected by sneezing. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. nodular tubercles. coughing. cheeselike (caseous) in appearance. are conglomerations of tubercles. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. In otherwise healthy children and adults. but most of the visible manifestations of tuberculosis. and a small scar in the lung may be visible by X-ray. sometimes called latent 116 . The Course of Tuberculosis The tubercle bacillus is a small. sometimes involving the use of five different agents. it can survive for months in a state of dryness and can also resist the action of mild disinfectants. the primary infection often heals without causing symptoms. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. In this condition.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. from barely visible nodules to large tuberculous masses. and the infected person acquires a lifelong immunity to the disease. The bacilli are quickly sequestered in the tissues. in which can be found many bacilli. Infections with these strains are often difficult to treat and require the use of combination drug therapies. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. A tubercle usually consists of a centre of dead cells and tissues. There the bacilli become trapped in the tissues of the body. are surrounded by immune cells. Individual tubercles are microscopic in size. rod-shaped bacterium that is extremely hardy. and finally are sealed up in hard.
kidneys. and the general health of the patient deteriorates. causing the patient to cough up blood (hemoptysis). These symptoms do not subside. This lesion may erode a neighbouring bronchus or blood vessel. causing miliary tuberculosis. the patient may have chest pain from pleurisy.7 Infectious Diseases of the Respiratory System 7 tuberculosis. sometimes after periods of time that can reach 40 years or more. The onset of pulmonary tuberculosis is usually insidious. In some cases the infection may break into the pleural space between the lung and the chest wall. the primary infection may spread through the body. before the advent of specific drugs. the elderly. releasing viable bacilli into the bloodstream. most commonly in the upper portion of one or both lungs. including the lymph nodes. this disease was always fatal. and bladder. though most affected people now recover. genital organs. This causes a condition known as pulmonary tuberculosis. usually with drenching night sweats. a highly fatal form if not adequately treated. a highly infectious stage of the disease. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. the cough increases. and immunocompromised adults (organ transplant recipients or AIDS patients. and persistent cough. or collection of fluid outside the lung. intestines. Particularly among infants. From the blood the bacilli create new tissue infections elsewhere in the body. Fever develops. In fact. weight loss. they can travel to almost any organ of the body. the original tubercles break down. causing a pleural effusion. An infection of the meninges that cover the brain causes tuberculous meningitis. for example). once the bacilli enter the bloodstream. however. Eventually. with lack of energy. skin. an alarming symptom. and there may be blood in the sputum. bones and joints. In the lung. Tubercular lesions 117 . In some cases. the affected person is not contagious.
along with the systematic identification and destruction of infected cattle. bovis. Pasteurization of milk kills tubercle bacilli. ulcerans. and it is also excreted in milk. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. is the cause of bovine tuberculosis. 118 . avium (or M. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. where it causes destruction of tissue and eventually gross deformity. The node swells under the skin of the neck. M. If the milk is ingested raw. From the gastrointestinal tract. and M. The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. bovis may spread into the bloodstream and reach any part of the body. M. causing large areas of destruction. marinum. finally eroding through the skin as a chronic discharging ulcer. often resulting in a hunchback deformity. M. aviumintracellulare). or Pott disease. M. kansasii. however. Tuberculosis of the spine. and scarring. atypical mycobacteria. where it causes caseation of the node tissue (a condition formerly known as scrofula). The amount of lung tissue available for the exchange of gases in respiration decreases. and this. and mycobacteria other than tuberculosis (MOTT). is characterized by softening and collapse of the vertebrae. has led to the disappearance of bovine tuberculosis in humans in many countries. bovis is transmitted among cattle and some wild animals through the respiratory route. This group includes such Mycobacterium species as M. a great preference for bones and joints. It shows. Other Mycobacterial Infections Another species of bacteria. M. cavities. bovis readily infects humans. M.7 The Respiratory System 7 may spread extensively in the lung.
An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. If bacilli are present. Injected into the skin. possibly in isolation until they are noninfectious. tuberculosis. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. in gastric washings. in which a sputum specimen is smeared onto a slide. and other organs only in people whose immune systems have been weakened. is composed of specially weakened tubercle bacilli. and this means treating infectious patients quickly. A vaccine. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. It has been widely used in some countries with success. Treatment is attempted with various drugs. and examined under a microscope. known as BCG vaccine. which confers some immunity to infection by M. but they cause dangerous illnesses of the lungs. its use in young children in particular has helped to control infection in the developing world. it causes a local reaction. In many developed countries. atypical mycobacterial illnesses are common complications of HIV infection. individuals at risk 119 . lymph nodes. Among AIDS patients. but the prognosis is usually poor owing to the AIDS patient’s overall condition. tuberculosis for several years. or in the cerebrospinal fluid. The main hope of ultimate control.7 Infectious Diseases of the Respiratory System 7 These bacilli have long been known to infect animals and humans. in the urine. however. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. stained with a compound that penetrates the organism’s cell wall. The primary method used to confirm the presence of bacilli is a sputum smear. lies in preventing exposure to infection.
As a result. and pyrazinamide. If a patient does not continue treatment for the required time or is treated with only one drug. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. These drugs are often used in various combinations with other agents. ethambutol. surgery is rarely needed. 120 . The patient is usually made noninfectious quite quickly. 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. of bed rest and surgical removal of useless lung tissue. bacilli will become resistant and multiply. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. making the patient sick again. such as health care workers. or rifapentine. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. Historically. If subsequent treatment is also incomplete. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. often years. the surviving bacilli will become resistant to several drugs. These drugs may be given daily or two times per week. but complete cure requires continuous treatment for another four to nine months. rifampicin. treatment of tuberculosis consisted of long periods. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. with early drug treatment. in order to avoid the development of drug-resistant bacilli. pyrazinamide. Today.7 The Respiratory System 7 for tuberculosis. such as ethambutol. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin).
in part to prevent the development and spread of MDR TB. 121 . the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. In 1995.7 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. such as kanamycin. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. 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. Aggressive treatment using five different drugs. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. 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. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. Instead of taking daily medication on their own. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. or capreomycin. MDR TB is treatable but is extremely difficult to cure. In addition. it has proved successful in controlling tuberculosis. amikacin.
ranging from inherited genetic mutations to smoking to trauma. diseases of the larynx. and cystic fibrosis. trachea. Conditions affecting these tissues may 122 . T diseases of the upper airway The nose. Treatment for this group of conditions is similarly varied. and lungs. they are by no means rigid. It is common for more than one part of the system to be involved in any particular disease process. palate. and in many cases therapy may include not only the administration of medications but invasive surgery as well. sinuses. bronchial tree. The causes of the various diseases and disorders are diverse. emphysema. Thus. and diseases of the mediastinum and diaphragm. Important examples of diseases and disorders of the respiratory system include sleep apnea. and disease in one region frequently leads to involvement of other parts. there are diseases of the upper airways.CHAPTER5 DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. and nasopharynx are all susceptible to disease. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. diseases of the pleura. Although these divisions provide a general outline of the ways in which diseases may affect the lung. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect.
cancer).. Snoring is more common in the elderly because the loss of tone in the oropharyngeal Although snoring bears the brunt of many jokes.e. a potentially life-threatening condition.7 Diseases and Disorders of the Respiratory System 7 result from a number of different causes. loud interrupted snoring can indicate sleep apnea. © www . Snoring Snoring is a rough. which necessitates breathing through the mouth.istockphoto. hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords. such as congenital structural abnormalities or malignant neoplastic changes (i. Such cancers are typically more common in smokers than in nonsmokers. It is often associated with obstruction of the nasal passages.com / Stephanie Horrocks 123 .
Children’s snoring usually results from enlarged tonsils or adenoids. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. It is also more common in men than in women. 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. body weight. which involves characteristics of both obstructive and central apneas. at which point the airway reopens and the person resumes breathing. and it occurs most often in obese persons. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. the condition has a strong association with certain measures of obesity. meaning “without breath. which is the most common form and involves the collapse of tissues of the upper airway.” There are three types of sleep apnea: obstructive. such as neck size. In addition. or body-mass index. Whatever the cause. The word apnea is derived from the Greek apnoia. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. In obstructive sleep apnea (OSA). In men shirt size is a useful predictor. with the likelihood of OSA increasing 124 . central. and mixed. Obstructive sleep apnea is most often caused by excessive fat in the neck area. airway collapse is eventually terminated by a brief awakening.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. Loud interrupted snoring is a regular feature of sleep apnea. Thus. a common and potentially lifethreatening condition that generally requires treatment.
and insulin resistance. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. The most common symptom of OSA is sleepiness. Sleep disturbance may cause difficulty concentrating. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. worsen short-term memory. Although CPAP does not treat the condition itself. which uses a mask (facial or nasal) during sleep to blow air into the upper airway.7 Diseases and Disorders of the Respiratory System 7 with a collar greater than about 42 cm (16. with many patients describing sleep as unrefreshing. 125 . the magnitude of the increased risk is the subject of some debate but is thought to be between three. However. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw.and sevenfold. with the resumption of breathing usually described as a gasp or a snort. including ischemic heart disease. The risk returns to normal after treatment. Other causes of the condition include medical disorders. it does prevent airway collapse and thus relieves daytime sleepiness. it is less certain that these diseases are caused by OSA. Treatment typically involves continuous positive airway pressure (CPAP). and increase irritability. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. The condition is also more common in patients with a set-back chin (retrognathia). Patients with OSA and sleepiness are at increased risk of motor vehicle accidents.5 inches). though surgery is seldom recommended. which can be resolved only by weight loss or treatment of underlying conditions. hypertension. such as hypothyroidism or tonsillar enlargement. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses.
oxygen in the blood is also significantly reduced. Individuals who have pickwickian syndrome often complain of slow thinking. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers.) This condition often occurs in association with sleep apnea. excessive fluid accumulates throughout the body (peripheral edema). The pleural membranes of the 126 . (By some definitions. diseases of the pleura The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. to be obese is to exceed one’s ideal weight by 20 percent or more. levels of carbon dioxide in the blood increase. thus increasing pressure in the vessels that supply the lungs. who showed some of the same traits. In more severe instances. an extremely obese person would exceed the optimum weight by a much larger percentage. also known as obesity hypoventilation syndrome. Low blood oxygen causes the small blood vessels entering the lungs to constrict. Because of inadequate removal of carbon dioxide by the lungs. ultimately causing right heart failure. leading to respiratory acidosis. in the space known as the pleural cavity. and fatigue.7 The Respiratory System 7 Pickwickian Syndrome Pickwickian syndrome. The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. The elevated pressure stresses the right ventricle of the heart. drowsiness. Finally. is a complex of respiratory and circulatory symptoms associated with extreme obesity. especially beneath the skin of the lower legs.
Mesothelioma. including tissues of the neck and head. by diffuse inflammatory conditions such as lupus erythematosus. In wet pleurisy. is an inflammation of the pleura. and treatment of the underlying disease. Pleurisy is commonly caused by infection in the underlying lung and. is an accumulation of watery fluid in the pleural cavity.7 Diseases and Disorders of the Respiratory System 7 lungs are also vulnerable to perforation and spontaneous rupture. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. Treatment of pleurisy includes pain relief. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. little or no abnormal fluid accumulates in the pleural cavity. rarely. fluids produced by the inflamed tissues accumulate within the pleural cavity. or hydrothorax. Pleurisy may be characterized as dry or wet. fluid evacuation. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. enabling air to enter the pleural cavity. Pleural Effusion and Thoracic Empyema Pleural effusion. Pleurisy Pleurisy. pleurisy can be very painful. Because the pleura is well supplied with nerves. This causes spontaneous pneumothorax. the membranes that line the thoracic cavity and fold in to cover the lungs. may occur many years after inhalation of asbestos fibres. a partial or occasionally complete collapse of the lung. There are many causes of 127 . also called pleuritis. In dry pleurisy. a cancer of the pleura. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath.
thereby preventing the accumulation of more fluid. As the inflammation heals. tuberculosis.7 The Respiratory System 7 pleural effusion. Treatment is directed at drainage of small amounts of pus through 128 . and bleomycin. Thoracic empyema may be characterized by fever. air may get into the pleural cavity. mesothelioma). coughing. The presence of both air and pus inside the pleural cavity is known as pneumothorax. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. such as malignant disease of the pleura (i. and fluid that seeps from the lungs places additional stress on the dysfunctioning heart. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. usually bacterial. It may also be caused by a lung abscess or some forms of tuberculosis. and the spread of a malignant tumour from a distant site to the pleural surface. Large pleural effusions can cause disabling shortness of breath. shortness of breath. or pyothorax. When the bronchial tree is involved in the infection. tissue adhesions obliterate the pleural space. This condition is often the result of a microbial. infection within the pleural cavity. a tube is inserted through the chest wall into the pleural space to drain the fluid.e. The accumulation of pus in the pleural cavity is known as thoracic empyema.. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. and the presence of fluid as ascertained by a chest X-ray. If symptoms of pleural effusion develop. and weight loss. doxycycline. 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. Under certain conditions. including pneumonia.
after which air is sucked through the opening and into the pleural sac. such as high-pressure mechanical ventilation. the heart. in tension pneumothorax air that becomes trapped in the pleural space cannot escape. 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. chest compression during cardiopulmonary resuscitation (CPR). and tension pneumothorax. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. or thoracoscopy (closed-lung biopsy). Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. lung infection. gunshot) or other injuries to the chest wall. In contrast to traumatic pneumothorax and spontaneous pneumothorax. Antibiotics are used to treat the underlying infection. air and pressure accumulate within the chest. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. or medical procedures. When the lung on the affected side of the chest collapses.7 Diseases and Disorders of the Respiratory System 7 a needle or larger amounts through a drainage tube. causing it to expand and thus compress the underlying lung. As a result. There are three major types of pneumothorax: traumatic pneumothorax. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. blood 129 . Pneumothorax Pneumothorax is a condition in which air accumulates in the pleural space. with each breath the patient inhales. which may then collapse. spontaneous pneumothorax.
may be present in childhood. many of these conditions are associated with irreversible lung damage. others may require surgery to prevent recurrences. In some cases. a catheter connected to a vacuum system is required to re-expand the lung. Whereas several diseases of the bronchi and lungs. thereby compressing the other lung. and airways are pushed to the centre of the chest. and excess sputum production and episodes of chest infection are common. The bronchi become chronically infected. This leads to decreases in blood pressure. diseases of the bronchi and lungs Diseases of the bronchi and lungs are often associated with significant impairments in respiration. including bronchiectasis and cystic fibrosis. clubbing (swelling of the fingertips and. While small pneumothoraxes may resolve spontaneously. This procedure allows air to escape from the chest cavity. The disease may also develop as a consequence of airway obstruction or of undetected (and 130 . occasionally. and breathing that in turn may lead to shock and death.7 The Respiratory System 7 vessels. Bronchiectasis Bronchiectasis is believed to usually begin in childhood. possibly after a severe attack of pneumonia. Most pneumothoraxes can be treated by inserting a tube through the chest wall. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. consciousness. In some cases. which enables the lung to reexpand. It consists of a dilatation of major bronchi. of the toes) may occur. In fact.
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 is sometimes caused by prolonged inhalation of environmental irritants.” without serious implications. or of organic substances such as hay dust. of which the most important is the familial disease cystic fibrosis. due to an increase in size and number of mucous glands lining the large airways. These therapies. now reach adult life.7 Diseases and Disorders of the Respiratory System 7 therefore untreated) aspiration into the airway of small foreign bodies. particularly in areas of uncontrolled coal burning. The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air. who would formerly have died in childhood. significant quantities of mucus are coughed up in the morning. enzyme therapy to thin the mucus. many of whom. Management of the condition includes antibiotics to fight lung infections. Chronic Bronchitis The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough. In some countries chronic bronchitis is caused by daily 131 . have helped control pulmonary infections and have markedly improved survival in affected persons. and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. This common condition is characteristically produced by cigarette smoking. in addition to others. medications to dilate the airways and to relieve pain. Bronchiectasis may also develop as a consequence of inherited conditions. After about 15 years of smoking. For example. such as parts of plastic toys.
It is not clear what determines the severity of these changes. Smoking-related chronic bronchitis often occurs in association with emphysema. 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. Because the damage to the bronchial tree is largely irreversible. The mucus-producing cough will subside within weeks or months and may resolve altogether. if severe enough. drugs to suppress paroxysmal coughing may be necessary. For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. consisting of expectorants and bronchodilators. By the time this occurs. The changes are not confined to large airways. whereas others may experience severe respiratory compromise after 15 years or less of exposure. though these produce the dominant symptom of chronic sputum production. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. Of primary importance is 132 . is severely compromised. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. Occasionally. Some people can smoke for decades without evidence of significant airway changes. but they must be used sparingly because they can be addictive and because expectoration is necessary. as measured by the velocity of a single forced expiration. ventilatory ability has usually been declining rapidly for some years. the ventilatory ability of the patient. in a cigarette smoker. All these changes together. the coexistence of these two conditions is known as chronic obstructive pulmonary disease. treatment is mainly symptomatic. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. though the rate of progression generally slows. Unfortunately.
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
Exacerbations are triggered by infection. it is increasingly recognized that COPD has secondary associations. indicate a poor prognosis. which work against bacteria. Although primarily a lung disease. particularly if severe enough to warrant hospital admission. air pollution.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. COPD is distinguished pathologically by the destruction of lung tissue. which 137 . Therefore. either bacterial or viral. are not always required. and the burning of certain fuels in poorly ventilated areas. Sources of noxious particles that can cause COPD include tobacco smoke. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). and by a tendency for excessive mucus production in the airway. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. tobacco-related condition. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). Coughing up blood is not a feature of COPD and when present raises concern about a second. which gives rise to symptoms of bronchitis. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. Frequent exacerbations. It is a common disease. including muscle weakness and osteoporosis.000 people in the United Kingdom and roughly 119. and each year about 30. which is replaced by holes characteristic of emphysema. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin.000 people in the United States die from COPD. antibiotics. particularly lung cancer. which causes increased lung volume and manifests as breathlessness.
. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD.e.e.. inability of the heart to function adequately). including noninvasive ventilation and surgical options (i. Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i.7 The Respiratory System 7 can be accomplished in most cases by cessation of smoking. Active congestion of the lungs is caused by 138 .. bronchodilators). Some COPD patients do not find oxygen attractive. 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. especially for patients with frequent exacerbations. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. oxygen is extremely flammable.to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy. or cardiac insufficiencies (i. which leads to further difficulties in mobility.e. This should be followed by a community/home maintenance program or by repeat courses every two years. In COPD patients with low blood–oxygen levels. since they need to use it for 16 hours each day to derive benefit. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. lung transplantation and lung-volume reduction). In addition. Specialized centres can offer treatments for patients with advanced disease. A six. Inhaled corticosteroids are commonly prescribed. high blood pressure.
In 139 . Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue. and the skin takes on a bluish tint as the disease progresses. when the remaining functioning tissue becomes infected. rather than whole blood. although there is usually enough unaffected lung tissue for respiration. narrowing of the valve between the upper and lower chambers in the left side of the heart. and particles. causes chronic passive congestion. there is a bloody discharge. Inflammatory edema results from influenza or bacterial pneumonia. and the precipitating causes may somewhat differ. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. caused by a cardiac disorder. 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. Eventually the pressure becomes too great. flooding them. liquids. Blood accumulates in the lower part of the lungs. and they begin to distend. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. or to relaxation of the blood capillaries followed by blood seepage. The major complication arises in mild cases of pneumonia.7 Diseases and Disorders of the Respiratory System 7 infective agents or irritating gases. Passive congestion is due either to high blood pressure in the capillaries. Mitral stenosis. The walls of the alveoli also thicken and gas exchange is greatly impaired. The blood pressure becomes high in the alveolar capillaries. The affected person shows difficulty in breathing. and blood escapes through the capillary wall into the alveoli. The alveolar walls and the capillaries in them become distended with blood.
Dr.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 .
and heavy. After an operation. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed. are not expanded with air. The term atelectasis can also be used to describe the collapse of a previously inflated lung. There are three major types of atelectasis: adhesive. Acute cases can be fatal in 10 to 20 minutes. the person may actually drown in the lung secretions. It can occur. with deep gurgling rattles in the throat. or air sacs. the blood pressure rises and edema ensues. This is typically caused by a failure to develop surface-active material 141 . either partially or fully. their lungs show areas in which the alveoli. and. These infants usually suffer from a disorder called respiratory distress syndrome. The term is derived from the Greek words atele s and ektasis.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. after reinflation of a collapsed lung. if too great a volume of intravenous fluids is given. compressive. A person with pulmonary edema experiences difficulty in breathing. because he or she is too weak to clear the fluids. The person’s skin turns blue. The lungs become pale. enlarged. wet. for unknown reasons. literally meaning “incomplete expansion” ¯ in reference to the lungs. because of specific respiratory disorders. and obstructive. Excessive irradiation and severe allergic reactions may also produce this disorder. 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. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. It may take only one or two hours for two to three quarts of liquid to accumulate.
7 The Respiratory System 7 X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242) 142 . Dr.
the anesthetic stimulates an increase in bronchial secretions. an enlarged heart. Other causes of obstruction include tumours or infection. The air passageways in the lungs normally secrete a mucous substance to trap dust. Local pressure can result from tumour growths. absence of respiratory movement on the side involved. Collapse is complete if the force is uniform or is partial when the force is localized. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. if these secretions become too abundant. which frequently enter with inhaled air. Treatment for infants with this syndrome includes replacement therapy with surfactant.7 Diseases and Disorders of the Respiratory System 7 (surfactant) in the lungs. causing air trapped in the alveoli to be slowly absorbed by the blood. and bacterial cells. displacement of the heart toward the affected side. they can be pushed out of the bronchi by coughing or strong exhalation of air. and respiratory function cannot be restored. the respiratory tissue is replaced by fibrous scar tissue. It may also occur as a complication of abdominal surgery. Treatment for obstructive and compressive 143 . and consolidation of the lungs into a smaller mass. and the muscles beneath the lungs may be weakened. Mucous plugs can result that cause atelectasis. soot. If a lung remains collapsed for a long period. When a person undergoes surgery. Generally. The symptoms in extreme atelectasis include low blood oxygen content. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out. which manifests as a bluish tint to the skin. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements. or elevation of the diaphragm. After abdominal surgery. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways.
and neck. however. near the muscular diaphragm that separates the chest cavity from the abdomen. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac. such blockages fail to cause death of tissue because the blood finds its way by alternative routes. The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. If the lung is congested. Ordinarily. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. The pain may be localized around the rib cage. Lung Infarction Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. lung infarctions can follow blockage of a blood vessel. When pain is present it indicates pleural involvement. 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). 144 . One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. or inadequately supplied with air. or it may be lower. infected. shoulders. Pain is most severe on inhalation. infarcts that occur deep inside the lungs produce no pain. or air bubbles in the bloodstream (both of these are instances of embolism).7 The Respiratory System 7 atelectasis is directed toward removal of any obstruction or compressive forces. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. The section of dead tissue is called an infarct. when the lungs are healthy.
the chief symptom of which is the production of a thick. However. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). The disorder was long known to be recessive (i.e. It is much less common among people of African ancestry (about 1 per 17. coughing. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. diminished breath sounds.. However. those individuals who have one normal copy and one defective copy of the particular gene involved). The dead tissue is replaced by scar tissue.000 live births) and is very rare in people of Asian ancestry. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry.. pleural rubbing. and a dull sound heard when the chest is tapped. only persons inheriting a defective gene from both parents will manifest the disease). is an inherited metabolic disorder.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. sticky mucus that clogs the respiratory tract and the gastrointestinal tract. 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. It is estimated to occur in 1 per 2. Infarcts that do not heal within two or three days generally take two to three weeks to heal. by the mid-1980s. also known as mucoviscidosis.000 live births in these populations and is particularly concentrated in people of northwestern European descent.e. increased heartbeat. when both 145 . moderate difficulty in breathing. The disease has no manifestations in heterozygotes (i. fever. Cystic Fibrosis Cystic fibrosis.
Cystic fibrosis affects the functioning of the body’s exocrine glands (e. the mucus-secreting and sweat glands) in the respiratory and digestive systems. 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. The thick. which is the most common cause of death of persons with cystic fibrosis. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet. About 10 146 . one out of four of their offspring will have the disease. lies in the middle of chromosome 7 and encodes a protein of the same name. recurrent pneumonia. called cystic fibrosis transmembrane conductance regulator. Chronic cough. Bulky. These functions are critical for maintaining and adjusting the fluidity of mucous secretions.7 The Respiratory System 7 parents are heterozygous. The gene.g. they may expect that. This results in chronic respiratory infections. often with Staphylococcus aureus or Pseudomonas aeruginosa. and the progressive loss of lung function are the major manifestations of lung disease. chloride and sodium ions accumulate within cells. plugging the bronchi and making breathing difficult. foul-smelling stools are often the first signs of cystic fibrosis.. As a result. sticky mucus accumulates in the lungs. on the basis of chance. Within the cells of the lungs and gut. In 1989 the defective gene responsible for cystic fibrosis was isolated. or CFTR. greasy. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. designated CFTR. the CFTR protein transports chloride across cell membranes and regulates other channels. In the digestive system.
as well as in the identification of newborns who may be at risk for the disorder. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. In addition. The high salt content in perspiration is the basis for the “sweat test.” which is the definitive diagnostic test for the presence of cystic fibrosis. and fat. protein.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. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. Medications such as dornase alfa. lung transplantation may be considered. a recombinant form of the enzyme deoxyribonuclease. 147 . are given to thin mucus. These tests are effective in the identification of adult carriers (heterozygotes). facilitating its clearance from the lungs through coughing. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. These agents may be administered by means of an inhaler or a nebulizer. In addition. Many patients with cystic fibrosis regularly take antibiotics. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. sometimes in aerosolized form. In severe cases. who may pass a mutation on to their offspring. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. Mutations associated with cystic fibrosis can be detected in screening tests. which is powered by a compressor that sprays aerosolized drug into the airways. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. in order to fight lung infections. making it easier for patients to breathe.
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 adenovirus associated virus. Since the 1990s. This first trial initially appeared to be successful.7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. However. 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. which subsequently incorporated the normal genes into their DNA. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. gene therapy for cystic fibrosis has undergone significant refinement. However. 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. and the outcomes of clinical trials are marked by steady improvement. including lung inflammation and signs of viral infection. 148 . Delivery systems under investigation include cationic polymer vectors. since increased expression of the CFTR protein was observed shortly after treatment. which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. 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. The latter. Gene therapy first emerged as a potential form of treatment in 1990. These vectors were then transfected into the cultured cells. the patients experienced severe side effects. cationic liposomes. As a result.
Other common changes are enlargement of the lymph 149 . A dry cough is common as well. Some individuals have clubbed fingertips and toes. or granulomas.” are heard through a stethoscope applied to the back in the area of the lungs. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. In addition. called rales or “Velcro crackles. with insidious onset of shortness of breath on exertion. in different organs. Sharp crackling sounds. Some individuals may benefit from single or double lung transplantation. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. some people live 10 years or longer. there is no effective treatment. The average duration of survival from diagnosis is four to six years. pulmonary function testing shows a reduction in lung volume. the lung is commonly involved. 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. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. however. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. Aside from administration of supplemental oxygen.7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis.
Pulmonary Alveolar Proteinosis Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. The alveoli are air sacs. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone.” leaving the lung with some permanent cystic changes. nerve sheaths are inflamed. The gas molecules must pass through a cellular wall. Although its cause is unknown. skin changes. the incidence is greatly increased in cigarette smokers. Evidence of granulomas in the lung may be visible. leading finally to lung fibrosis and respiratory failure. The kidney is not commonly involved.7 The Respiratory System 7 glands at the root of the lung. but some changes in blood calcium levels occur in a small percentage of cases. a complex mixture of protein and lipid (fat) molecules. When too much surfactant is released from the alveolar cells. In most cases the disease is first detected on chest radiographs. Occasionally. or when the lung fails to remove the 150 . but often there is little interference with lung function. inflammation in the eye. but in a small proportion of cases it progresses. also known as histiocytosis X. Eosinophilic granuloma is a lung condition that may spontaneously “burn out. The disease usually remits without treatment within a year or so. is a disease associated with the excess production of histiocytes. leading to signs of involvement in the affected area. minute structures in the lungs in which the exchange of respiratory gases occurs. a subgroup of immune cells. It causes lesions in lung tissue and sometimes also in bone tissue. and liver dysfunction. the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. Eosinophilic granuloma.
The disease can exist without causing symptoms for considerable periods. Persons affected are usually between ages 20 and 50. 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. There may also be general fatigue and weight loss. The precipitating cause of the disease is unknown. X-rays most frequently show evidence of excess fluids in the lungs. is an important cause of pulmonary blood vessel inflammation. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. but rarely so. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. but subsequent treatments are often necessary. Immunologic Conditions of the Lung The lung is often affected by generalized diseases of the blood vessels. and spontaneous improvement has been known to occur. The condition has been successfully treated by exchange blood transfusion. an acute inflammatory disease of the blood vessels believed to be of immunologic origin. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. Sometimes the lesions totally clear up after one procedure. but its cause is not fully understood. Wegener granulomatosis. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. Treatment involves removal of the material by a rinsing out of the lungs (lavage). it is sometimes fatal. if treated.7 Diseases and Disorders of the Respiratory System 7 surfactant. The skin becomes tinged with blue in the most serious cases. The fluids drawn back out of the lungs have been found to have a high content of fat. Pulmonary hemorrhage also occurs as part of a condition 151 .
and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. Lung cancer was first described by doctors in the mid-19th century. accurate diagnosis has been much improved by refinements in radiological methods. More rarely. resulting in an estimated 1. lung cancer is the second leading cause of death from cancer globally. following breast cancer. Pleural effusions may occur. The common condition of rheumatoid arthritis may be associated with scattered zones of interstitial fibrosis in the lung or with solitary isolated fibrotic lesions. Lung Cancer Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs. These conditions have only recently been recognized and differentiated. a slowly obliterative disease of small airways (bronchiolitis) occurs. 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. however.7 The Respiratory System 7 known as pulmonary hemosiderosis. In women. 152 . it has surpassed breast cancer.3 million deaths each year. leading finally to respiratory failure. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. which is also believed to have an immunologic basis. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. by the use of pulmonary function tests. In the United States. lung cancer emerged as the leading cause of cancer deaths worldwide. In the early 20th century it was considered relatively rare. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. In the 21st century.
visible lumps. Other risk factors include exposure to radon gas and asbestos. the tumour’s type and degree of invasiveness are determined. In countries with a prolonged history of cigarette smoking. tar refiners. and workers exposed to halogenated ethers also have an increased incidence. such as coal processors. chest pain. Uranium and pitchblende miners. The risk is also greater for those who started smoking at a young age. The most common symptoms include shortness of breath. bloody sputum. secondhand smoke accounts for an estimated 3. According to the American Cancer Society. between 80 and 90 percent of all cases are caused by smoking. a persistent cough or wheeze. and roofers. small-cell 153 . Of the two basic forms. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. unexplained weight loss. Tumours can begin anywhere in the lung. jaundice. Heavy smokers have a greater likelihood of developing the disease than do light smokers. welders. In cases where the cancer has spread beyond the lungs.400 deaths from lung cancer in nonsmoking adults in the United States each year.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. and susceptibility to lower respiratory infections. Lung cancer is rarely caused directly by inherited mutations. Types of Lung Cancer Once diagnosed. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. as do some workers in hydrocarbon-related processing. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. or bone pain may occur. chromium and nickel refiners.
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.or column-shaped. pleura. or shaped like oat grains. also called epidermoid carcinomas. the survival rate is very low. oval. and they form structures that resemble glands and are sometimes hollow. but it is the most common type of lung cancer in the United States. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. It is characterized by cells that are small and round. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. and Prevention Lung cancers are often discovered during examinations for other conditions. scalelike cells. This tumour is characterized by flat. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. Tumours often originate in the smaller. Because it tends to spread quickly before symptoms become apparent. Cells of adenocarcinoma are cube. and it often develops in the larger bronchi of the central portion of the lungs. Treatment. SCLC is the most aggressive type of lung cancer. 154 . About 10 percent of all lung cancers are large-cell carcinomas. Small-cell carcinoma (SCLC). and large-cell carcinoma. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. and both lungs or metastasis to other organs. also called oat-cell carcinoma. Diagnosis. Cancer cells may be detected in sputum. adenocarcinoma. is rarely found in people who have never smoked. 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. peripheral bronchi.
or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. The choice of treatment depends on the patient’s general health. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. computed tomography (CT) scans. For example. the five-year survival rate is about 50 percent. the stage or extent of the disease. and radiation. Noninvasive methods include X-rays. treatments for lung cancer include surgery. and the type of cancer. Surgery involves the removal of a cancerous segment (segmentectomy). Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer.7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. As with most cancers. Even when it is detected early. and magnetic resonance imaging (MRI). positron emission tomography (PET) scans. lung cancer has a poorer prognosis than many other cancers. The type of treatment an individual patient receives may also be based on the results of genetic screening. Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. For this reason. a lobe of the lung (lobectomy). or the entire lung (pneumonectomy). which can identify mutations that render some lung cancers susceptible to specific drugs. Lung surgery is serious and can lead to complications such as pneumonia or bleeding. chemotherapy. 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.
or additional damage to the lungs. causing side effects that are similar to radiation therapy. Smokers who quit also reduce their risk significantly. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. together with the many important structures situated within it. which relies on heat derived from microwave energy to kill cancer cells. asbestos. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. 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. Side effects include vomiting. noninvasive cysts of different kinds are also found in the mediastinum. and other airborne carcinogens also lowers risk. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the 156 . fatigue. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. but these chemicals also attack normal cells to varying degrees. The probability of developing lung cancer can be greatly reduced by avoiding smoking.7 The Respiratory System 7 following surgery to destroy small amounts of cancerous tissue. Chemotherapy uses chemicals to destroy cancerous cells. Testing for radon gas and avoiding exposure to coal products. diarrhea.
Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. Air trapped in the mediastinum expands as the diver continues to rise. however. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. there is no difficulty. While the diver remains deeply submerged. rises too rapidly. or they can travel through the lung tissue to other areas of the body. As a diver descends. If the diver holds his or her breath. when he or she begins to ascend again. the lungs become overinflated and rupture. the external pressure upon his or her body increases. causing an air embolism. and the lungs begin to expand because the air inside has less pressure to contain it. or scar tissue. making breathing difficult. Air bubbles can then enter the veins and capillaries of the circulatory system directly. If the diver breathes normally or exhales as he or she ascends at a moderate rate. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. which do not permit sufficient release of air. This area contains the heart. and the trachea. the external pressure decreases. major blood vessels. the released air seeks an area of escape. mucus plugs. the expanding air may compress the respiratory passageways. One pathway that the air can follow is through the lung tissue into the mediastinum. The pressure may cause intense pain beneath the rib cage and in the shoulders. The air the diver breathes is more dense and concentrated than the air breathed on the surface. main bronchi. When the alveoli of the lungs rupture because of traumatic injury or lung disease. and collapse blood vessels vital to circulation. 157 . or has respiratory obstructions such as cysts. This usually occurs as a result of lung rupture. the extra gas pressure is relieved by exhaling.7 Diseases and Disorders of the Respiratory System 7 heart and central blood vessels.
the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. respiratory failure. and cyanosis (blue colouring of the skin). 158 . the air will be absorbed by the body. especially when the subject is recumbent (lying down).7 The Respiratory System 7 The symptoms of mediastinal emphysema may range from pain under the breastbone. In some persons the diaphragm may be incompletely formed at birth. In cases in which the symptoms are not severe. The function of the diaphragm may be compromised when the lung is highly overinflated. shock. In many cases the cause of the paralysis cannot be determined. bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. this can lead to herniation of the abdominal viscera through the diaphragm. For example. diaphragmatic fatigue may limit the exercise capability of affected persons. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air. although some shortness of breath on exertion is often present. and shallow breathing to unconsciousness. as occurs in emphysema. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. If there is respiratory or circulatory distress.
A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. hence.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. For most affected persons. severe respiratory disease may ensue. such as asbestos and coal dust. 159 . causes respiratory disease in otherwise healthy workers. In occupational disease. Carbon monoxide poisoning. In the case of allergies. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. In some cases of occupational exposure. Respiratory function can be severely compromised by a variety of other conditions. decompression sickness. altitude sickness. such as respiratory distress syndrome. For example. traumatic conditions. and. exposure to harmful irritants. First. many of which are acute in nature. leading to cancer and substantial loss of lung function. and drowning are other examples of acute conditions that can result in respiratory failure. however. reducing exposure to the irritant relieves the symptoms of their condition. affected persons are highly sensitive to substances such as dust or pollen.
It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. however. or sinusitis. Adult asthma is sometimes linked to exposure to certain materials in the workplace. Although an initial episode can occur at any age. The most common and most important of these is asthma. and breathlessness that range in severity from mild to life-threatening. that may induce an allergic reaction. and grains. In addition. and. asthma may develop in response to allergens. stress may exacerbate symptoms.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. such as chemicals. causing episodes of wheezing. These substances provoke both allergic and nonallergic forms of the disease. chest tightness. boys being affected more often than girls. In adults. dust mites. and exercise may cause it as well. coughing. it is often associated with an inherited susceptibility to allergens— substances. Adults who develop asthma may also have chronic rhinitis. which may be involved in any general inflammatory response. Among adults. or animal dander. but viral infections. When asthma develops in childhood. women are affected more often than men. wood dusts. weather conditions. nasal polyps. Asthmatic episodes may begin suddenly or may take days to develop. In 160 . 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. the lung contains a very large vascular bed. aspirin. such as pollen. approximately half of all cases occur in persons younger than age 10. third. second.
Inc. air is obstructed from circulating freely in the lungs and cannot be expired. moderate persistent. most of these cases. Consequently. in general 161 . terminal bronchial tubes. symptoms will subside if the causative agent is removed from the workplace. Encyclopædia Britannica.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. Asthma is classified based on the degree of symptom severity. Although the mechanisms underlying an asthmatic episode are not fully understood. and severe persistent. During an asthma attack. mild persistent. smooth muscles that surround the airways spasm. which can be divided into four categories: mild intermittent. narrower passages (bronchioles) and finally into the tiny. 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. which results in tightening of the airways. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller.
which are bronchodilators. which are anti-inflammatory medications often prescribed for children. swelling and inflammation of the bronchial tubes. which suppress inflammation. long-acting beta2-agonists and methylxanthines (e. Long-term control medications include corticosteroids. which are involved in mediating airway constriction and inflammation. which relax smooth muscle constriction and open the airways. or they may be used to provide rapid relief from constriction of airways (quick-relief medications).g. theophylline). air is inspired but cannot be expired). A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. The inflamed.. are in clinical trials.e. which are the most potent and effective anti-inflammatory medications available. These 162 . which are leukotriene modifiers. bronchodilators. The obstruction of airflow may resolve spontaneously or with treatment. or systemic corticosteroids. cromolyn sodium and nedocromil. which interrupt the chemical signaling within the body that leads to constriction and inflammation. and zileuton and zafirlukast. mucus-clogged airways act as a one-way valve (i. Quick-relief medications may include bronchodilators. and leukotriene modifiers. Agents that block enzymes called phosphodiesterases. and excessive secretion of mucus into the airways. Asthma medications are categorized into three main types: anti-inflammatory agents. 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). such as shortacting beta2-agonists and ipratropium bromide.7 The Respiratory System 7 it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system..
exposure to secondhand smoke. Reasons for this dramatic surge in asthma cases. particularly among children. crowded living conditions. are not entirely clear. and even cockroaches have been blamed for the increase. Today asthma affects more than 7 percent of children and about 9 percent of adults. A prolonged asthma attack that does not respond to medication is called status asthmaticus. can relieve symptoms of allergy and asthma. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. a species of hookworm. millions of people are infected with Necator americanus. In addition to managing asthma with medications. Further investigation of this “helminthic therapy” in larger sample populations is under way. In developed countries and especially in urban areas. too few to cause hookworm disease. the number of asthma cases has increased steadily. in many underdeveloped tropical regions of the world. smoking. very few people are affected by allergies or asthma. In those areas. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. A person with this condition must be hospitalized to receive oxygen and other treatment. which may cause cardiovascular damage. 163 . Air pollution. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. However. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma.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. The ability to recognize the early warning signs of an impending episode is important.
which irritates the small blood vessels and mucus-secreting glands. studies have indicated that only one vaccine. such as ragweed in North America and timothy grass in Great Britain. like other allergic diseases. Seasonally recurrent bouts of sneezing. pertussis vaccine. Antibiotics may also interfere with immune development. also known as allergic rhinitis. The most effective long-term treatment is immunotherapy. 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). Although not yet successfully confirmed. In a reverse scenario. and tearing and itching of the eyes caused by allergy to the pollen of certain plants.7 The Respiratory System 7 There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. 164 . is a common seasonal condition caused by allergy to grasses and pollens. such as dermatitis or asthma. may give rise to asthma. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. In allergic persons contact with pollen releases histamine from the tissues. Symptoms may be aggravated by emotional factors. desensitization by injections of an extract of the causative pollen administered once or twice a week for one or more years. chiefly those depending upon the wind for cross-fertilization. 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. nasal congestion. Hay fever. shows a familial tendency and may be associated with other allergic disorders. Hay Fever Hay fever.
Louise K. Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Giant ragweed (Ambrosia trifida) is a common cause of hay fever. Broman—Root Resources 165 .
Farmer’s lung is common in Wisconsin. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). on the eastern seaboard of Canada. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. or becoming opaque) in the basal regions of the lung on the chest radiograph. granulomas. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. and there may be measurable interference with diffusion of gases across the alveolar wall. with inflammation of the smaller bronchioles. these represent different kinds of allergic responses to proteins from birds. after 166 . with shortness of breath persisting after the radiographic changes have disappeared.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. particularly proteins contained in the excreta of pigeons. alveolar wall edema. may be found in the lung. or aggregations of giant cells. Variously known as pigeon breeder’s lung or bird fancier’s lung. This causes an acute febrile illness with a characteristically fine opacification (clouding. and canaries. If untreated. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. In more chronic forms of the condition. in the west of England. budgerigars (parakeets). Airflow obstruction in small airways is present. A similar group of diseases occurs in those with close contact with birds. One of these illnesses is the so-called farmer’s lung. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). and in France. the condition may become chronic.
but sometimes the precise agent cannot be identified. 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. or in response to a variety of other agents. Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. It is occasionally attributable to Aspergillus. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. 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.
As little as 5 or 6 grams (about 0. Typically. shortness of breath. The total dust load in the lung. tin. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. the toxic effects of certain types of dust. progressing to more serious breathing impairment.7 The Respiratory System 7 irritants. clay. lung function is seriously impaired. is the most common cause of severe pneumoconiosis. often after relatively brief 168 . produce grave reactions. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. beryllium. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses.2 ounce) in the lung can produce disease. The type and severity of disease depends on the composition of the dust. barium. and cough. usually over a prolonged period of time. and infections of the already damaged lung can accelerate the disease process. silica. If enough scar tissue forms. and aluminum dusts can cause a more severe pneumoconiosis. small quantities of some substances. and the clinical symptoms of pneumoconiosis are manifested. Graphite. although silica exposure is also involved in many cases. while milder irritants produce symptoms of lung disease only with massive exposure. Inhaled dust collects in the alveoli. Among inorganic dusts. encountered in numerous occupations. iron. chronic bronchitis. notably silica and asbestos. and emphysema in the most severe cases. or air sacs. Asbestos. chromate. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. the early symptoms of mild pneumoconioses include chest tightness. and coal dusts are other inorganic substances known to produce pneumoconiosis. of the lung.
and it remains one of the most common dust-induced respiratory diseases in the developed world. and buffing.) The disease occurs most commonly in miners. ammonia. tunnelers. the patient may recover completely or may suffer from chronic bronchitis or asthma. and workers whose jobs involve grinding. Asbestosis has also been associated with cancers of the lung and other organs. stimulate histamine release. flax. and chloride. (Silica is the chief mineral constituent of sand and of many kinds of rock. Chemical irritants that have been implicated in lung disease include sulfur dioxide. Once exposure to the chemical ceases. or hemp that. The 169 . Prolonged exposure to organic dusts such as spores of molds from hay. malt.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 exposure to massive amounts of dust. nitrogen dioxide. and their irritant effect may cause large amounts of fluid to accumulate in the lungs. quarry workers. even in previously nonallergic persons. In most instances. Silicosis is one of the oldest industrial diseases. when inhaled. The chemicals themselves may scar the delicate lung tissues. having been recognized in knife grinders and potters in the 18th century. which are quickly absorbed by the lining of the lungs. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. stonecutters. and barley can produce lung disease through a severe allergic response within a few hours of exposure. impeding exhalation. Histamines cause the air passages to constrict. Brown lung disease in textile workers is also a form of pneumoconiosis. mushrooms. caused by fibres of cotton. polishing. sandblasting. Silicosis Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. acid. sugarcane.
000 particles of silica per cubic foot (about 210.0004 inch) in diameter penetrate to the finer air passages of the lungs.000. 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. since there is no effective treatment. and pneumonia. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. Only very small silica particles less than 10 microns (0. and.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses. Black Lung Black lung. is a respiratory disorder caused by repeated inhalation of 170 . Silica particles. These whorls of fibrous tissue may spread to involve the area around the heart. There is no cure for silicosis. the openings to the lungs. though this has changed with the availability of drug therapies for that disease. control of the disease lies mainly in prevention. and weakness. cannot be digested by the macrophages and instead kill them. and gas exchange is poor. Silicosis predisposes a person to tuberculosis. In the past a large proportion of sufferers of silicosis died of tuberculosis. and particles of one to three microns do the most damage. that serve to protect the body from bacterial invasion. however. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. In the actual disease process. emphysema. Lung volume is reduced. also known as coal-worker’s pneumoconiosis.000 per litre) of air. called macrophages. difficulty in breathing. and the abdominal lymph nodes. The symptoms of silicosis are shortness of breath that is followed by coughing.
whether coal itself is solely responsible for the disease. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. Georgius Agricola. first described lung disease in coal miners in the 16th century. ceiling tiles. which causes similar symptoms. brake linings. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. a German mineralogist. It may be the best known occupational illness in the United States. Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. 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. and the extent of disease is clearly related to the total dust exposure. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. as coal dust often is contaminated with silica. The disease is most commonly found among miners of hard coal. tuberculosis is also more common in victims of black lung. and it is now widely recognized. There is strong evidence that tobacco smoking aggravates the condition. Onset of the disease is gradual. but it also occurs in soft-coal miners and graphite workers. The early stages of the disease (when it is called anthracosis) usually have no symptoms. led to a virtual epidemic of asbestos-related disease 20 years later. and as a fire protectant sprayed inside buildings. It is not clear. and later in flooring.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 coal dust over a period of years. however. 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.
but survival after diagnosis is less than two years. thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. especially when associated with cigarette smoking. is inhaled than if chrysotile is inhaled. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer. In most cases. inhalation of asbestos remains a significant risk for the workers removing the material. Malignant mesothelioma is rare and unrelated to cigarette smoking. a blue asbestos that comes from South Africa. 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. although in occasional cases pleuritis is very aggressive and thus may produce symptoms. These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. when both cigarette smoking and asbestos exposure occurred. All 172 . and. As far as is known. there was a major increase in the risk for lung cancer. Not all types of asbestos are equally dangerous. all the respiratory changes associated with asbestos exposure are irreversible. It is not yet understood exactly why asbestos devastates the tissues of the lungs. Asbestos has been suspected to play a role in stimulating certain cellular events. But exposure to any type of asbestos is believed to increase the risk of lung cancer.7 The Respiratory System 7 thickening of the pleura. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people.
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.
when the infarction is massive. and occasionally some pleuritic pain over the site of the infarction. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. which has usually formed in the veins of the legs or of the pelvis. a clot is replaced with 177 . slight fever. Early mobilization after surgery or childbirth is considered an important preventive measure. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. comprise a diverse group of diseases and disorders. In addition. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. The causative factors of these conditions may include accidents. Over time. This occurs most often during a postoperative period when the affected individual is immobilized in bed. these changes are known as a pulmonary infarction. When severe. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. Circulatory Disorders The lung is commonly involved in disorders of the circulation. ranging from poor pulmonary circulation to carbon monoxide poisoning. toxic gases. environmental pollutants. and metabolic disorders. which occurs during mountain climbing and diving. to an increased respiratory rate. in which the pressure in the main pulmonary artery is persistently increased. conditions arising from exposure to extremes in atmospheric pressure. The consequences of embolism range from sudden death. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health.
lung transplantation is necessary. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. ultimately. usually as a consequence of coronary arterial disease. When the 178 . follows left ventricular failure. and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. thereby relieving symptoms of breathlessness. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. In addition to chest X-rays and basic pulmonary function tests. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. While some medications such as calcium channel blockers may be taken orally. right ventricular heart failure. In primary pulmonary hypertension. a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. a condition of unknown origin. usually after increasing disability with severe shortness of breath. In some cases. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. long-term evaluation and treatment. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. with consequent shortness of breath. The obstructing lesions can be surgically removed in some instances. affected individuals require careful.7 The Respiratory System 7 an adherent fibrous material in the pulmonary arteries. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. causing shortness of breath on exertion and. Prostacyclin can sometimes be given in oral or inhaled forms.
or approximately 5. It is characterized by extremely laboured breathing. which does the work of the lungs by oxygenating the 179 .5 kg. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. These changes contribute to the shortness of breath and account for the blood staining of the sputum. Although respiratory distress syndrome occurs mostly in premature.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). In infants it is also called hyaline membrane disease. low-birth-weight infants (those weighing less than 2. This complication is especially common in premature newborns. 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. respiratory distress syndrome of infants was frequently fatal. it also sometimes develops in full-term infants. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. cyanosis (a bluish tinge to the skin or mucous membranes). The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. The syndrome was formerly the leading cause of death in premature infants. The disorder arises because of a lack of surfactant. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken.5 pounds). Before the advent of effective treatment. and abnormally low levels of oxygen in the arterial blood. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. particularly those born to diabetic mothers.
Prize cattle at an agricultural show also died in the same period as a result of the air pollution.000 people during that week and the subsequent three weeks. exposure of the lung to gases. This episode spurred renewed attention to this problem. bacterial or viral pneumonia. In adults. widespread bilateral lung injury. Many. Life-support treatment with assisted ventilation rescues many patients. 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. which had been intermittently considered since the 14th century 180 . The continual air pressure provided by the ventilator prevents the collapse of the air sacs. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. Recovery and repair of the lung may take months after clinical recovery from the acute event. 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. but not all. Many causes of respiratory distress syndrome of adults have been identified. Most children who survive have no aftereffects. although superimposed infection or multiple organ failure can result in death. Acute respiratory distress syndrome carries about a 50 percent mortality rate. of the victims already had chronic heart or lung disease. aspiration of material into the lung (including water in near-drowning episodes). or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. This syndrome is known as acute respiratory distress syndrome of adults.7 The Respiratory System 7 blood and removing carbon dioxide.
the factor most responsible for the pollution. This begins with the emission Air pollution begins as emissions from sources such as industrial smokestacks.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 in England. leads to the formation of photochemical smog. The large number of automobiles in that city. common in many cities using coal as heating fuel. respiratory tract infections in the young and old. and possibly lung cancer.com/Jupiterimages 181 . In 1952 a different kind of air pollution was characterized for the first time in Los Angeles. Photos. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. is associated with excess mortality and increased prevalences of chronic bronchitis. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories. This form of pollution. together with the bright sunlight and frequently stagnant air. and finally the passage of legislation banning open coal burning.
7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. and São Paulo. 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. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. followed by the formation of nitrogen dioxide by oxygenation. In developing countries.12 part per million. and possibly the exacerbation of asthma occur as a result. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. The indoor environment can be important in the genesis of respiratory disease. 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. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. including Mexico City. Eye irritation. and finally. Bangkok. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. 182 . chest irritation with cough. Such exposures are common in the lives of millions of people. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. through a complex series of reactions in the presence of hydrocarbons and sunlight. and the impact of these exposures is an area of intense scientific investigation. In developed countries. Ozone is the most irritant gas known. which begins as emissions of nitrogen oxides. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration.
leaving only 60 percent available to bind to oxygen). as part of his detailed analysis of atmospheres in underground mines. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. For this reason. including combustion of gas in automobile engines. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). a condition in which hemoglobin is deficient. 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. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. 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. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. 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. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. 183 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. Judgment is also impaired. 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.
such as general anesthetic agents.7 The Respiratory System 7 Acidosis Acidosis is an abnormally high level of acidity. or pneumonia. which may be caused by anxiety. Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. including the blood. or bicarbonate gain. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. Respiratory alkalosis results from hyperventilation. Metabolic alkalosis results from either acid loss. 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. such as pneumonia or emphysema. or by certain medications that suppress respiration in excessive doses. pulmonary embolism. including the blood. There are two primary types of acidosis: respiratory and metabolic. certain drugs or poisons. or high level of alkalinity. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. in the body fluids. among others. and renal failure. Causes of metabolic acidosis include uncontrolled diabetes mellitus. congestive heart failure. Alkalosis and Hyperventilation Alkalosis is an abnormally low level of acidity. shock. Alkalosis may be either metabolic or respiratory in origin. Hyperventilation is defined as a sustained abnormal increase in breathing. asthma. This may be caused by severe acute or chronic lung disease. in the body fluids. or low level of alkalinity. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). During hyperventilation the rate of 184 .
Encyclopædia Britannica. 185 . accumulation of fluid in the alveolar spaces can interfere with gas exchange. In addition. Imbalances in the exchange of these gases can lead to dangerous respiratory disorders.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. such as respiratory acidosis or hyperventilation. Inc. causing symptoms such as shortness of breath.
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.7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. and these dissolved gases come 190 . underwater divers. the pleural spaces. such as the ears. Pilots of unpressurized aircraft. For example. there are air pockets that either expand or contract in response to changes in pressure. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. A fatal form of barotrauma can occur in submariners and divers. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). or under the skin of the neck. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. lungs. and intestines. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. the external pressures upon his or her body decrease. small amounts of the gases that are present in the air. however. In certain cavities of the body. face. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. and torso. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. in solution. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). At atmospheric pressure the body tissues contain. 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. such as the eardrum. When a pilot ascends to a higher altitude. 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. sudden expansion of air trapped within the thorax can burst one or both lungs.
Conversely. often associated with a sharp retrosternal pain on deep inspiration. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 out of solution. Therefore.” The major component of air that causes decompression maladies is nitrogen. When the pressure decreases. speech defects. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). 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. Nitrogen is much more soluble in fatty tissue than in other types. rapid respiration. nausea. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s 191 . If the ascent is slow enough. signals the onset of pulmonary decompression sickness. as the affected person commonly is unable to straighten joints. spinal cord. The nervous system is composed of about 60 percent lipids. numbness. and personality changes. When bubbles accumulate in the joints. The term bends is derived from this affliction. pain is usually severe and mobility is restricted. the “chokes. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). the gases have time to diffuse from the tissues into the bloodstream. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. Bubbles forming in the brain. Shallow. The gases then pass to the respiratory tract and are exhaled from the body. the excess nitrogen is released. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled.
If compression continues. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. Other symptoms include chest pain. indicate nitrogen bubbles in the respiratory system. Thoracic Squeeze Thoracic squeeze. the lung shrinks to about one-fourth its size at the surface. known as the chokes. Usually these symptoms pass in 10 to 20 minutes. The outer linings of the lungs (pleural sacs) may separate from the chest wall. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. 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). the air inside the lungs is compressed. or lung squeeze. while too little air causes compression and collapse of the lung walls. a burning sensation while breathing. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. During the descent. Because the lung tissue is elastic and interspersed with tubules and sacs of air. but this process is not always able to reverse damage to tissues. 192 . is a type of barotrauma involving compression of the lungs and thoracic cavity. an increase in pressure causes air spaces and gas pockets within the body to compress. Too much air causes rupture of lung tissue. Excessive coughing and difficulty in breathing. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. It most commonly occurs during a breath-holding dive underwater. If one descends to a depth of about 30 metres (100 feet).7 The Respiratory System 7 itches. and the lung may collapse. and the size of the lungs decreases. and severe shock.
and gives up the remaining tidal air in his or her lungs. Artificial respiration may be necessary if the breathing has stopped. more than 10 times the depth that humans can tolerate. and their bodies are adapted to use the gases in the bloodstream more conservatively. usually water. 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. pulse. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. although they lack evidence of life. There the heart may continue to beat feebly for a brief interval. and may even become unconscious.300 feet). do not separate from the chest wall. A fuller appreciation of the 193 . may exhale frothy blood. loses consciousness. The sperm whale is reported to dive to about 1.7 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. It is now known that victims immersed for an hour or longer may be totally salvageable. but eventually it ceases. the diver may have difficulty in breathing. Deprived of oxygen the victim stops struggling.000 metres (3. Drowning Drowning is suffocation by immersion in a liquid. having no measurable vital signs—heartbeat. 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. which can be relieved by ascending. Any symptoms of thoracic squeeze call for prompt medical attention. their lungs. These aquatic mammals have been found to have more elastic chest cavities than humans. even when reduced. or breathing—at the time of rescue. If the thoracic squeeze has been sufficient to cause lung damage. Until recently.
actual aspiration of water into the lungs may or may not occur. quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. The mechanism is powerful in children. the volume of fluid entering the lungs rarely exceeds a glassful. A natural biological mechanism that is triggered by contact with extremely cold water. so that many people who once would have been given up for dead are being saved. Scientists have determined that vestiges of the reflex persist in humans. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. 194 . known as the mammalian diving reflex. In this suspended state. abdomen. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. despite a total absence of respiratory gas exchange. Up to 15 percent of drownings are “dry. in other respects it performs normally. and surface areas of the body to the heart and the brain. thus permitting seagoing mammals to hunt for long periods underwater. enhances survival during submersion. It diverts blood from the limbs.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. Often. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. Even though the heart functions at a slower rate. When aspiration does occur.
6 °F (17 °C) have survived. 195 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. 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).” “Lifeless” immersion victims with core temperatures as low as 62. slows the heart rate. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia. and promotes unconsciousness. survival following hypothermic coma is almost 75 percent. None of these effects is imminently life-threatening. Such warmwater drownings occur commonly in domestic bathtubs. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain.
and pathology of the human respiratory system is known as pulmonology. physiology. especially in the area of disease prevention. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. Today.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. Likewise. This expansion of scientific understanding has enabled important progress in respiratory medicine. A cough productive of sputum is the most important manifestation of inflammatory or 196 . In addition. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. have contributed to improvements in the diagnosis and evaluation of respiratory disease. many technological advances. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. particularly concerning techniques employing X-ray imaging or endoscopy. 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. or respiratory medicine. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart.
resulting from occupational lung disease or arising from no identifiable antecedent condition. or with the onset of a severe attack of asthma. capillary damage. of which bronchitis is a common example. may also cause severe and unremitting dyspnea. or walking uphill.7 Approaches to Respiratory Evaluation and Treatment 7 malignant diseases of the major airways. such as walking up a flight of stairs. playing golf. as when a foreign body is inhaled into the trachea. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. 30 to 60 ml of sputum are produced in a 24-hour period. but in diseases such as emphysema. of complex origin. the lung capillaries become engorged. Severe fibrosis of the lung. and. This sensation. it may also indicate the presence of inflammation. What is noted is a slowly progressive difficulty in completing some task. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. and tasks such as dressing cannot be performed without difficulty. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. It may become so severe as to immobilize the victim. The shortness of breath may vary in severity. More often. in which there is irreversible lung damage. may arise acutely. it is constantly present. or a tumour. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. The second most important symptom of lung disease is dyspnea. commonly. Hemoptysis is also a classic sign of tuberculosis of the lungs. When this occurs. it is insidious in onset and slowly progressive. if the right ventricle that pumps blood through the lungs is functioning normally. and fluid may accumulate in 197 . or shortness of breath. Although it may result simply from an exacerbation of an existing infection. particularly in the first two hours after awakening in the morning.
which leads to acute congestion of the affected part. To these major symptoms of lung disease—coughing. Acute pleurisy with pain may signal a blockage in a pulmonary vessel. for example. It is commonly dyspnea that first causes a patient to seek medical advice. For example. This is caused by narrowing of the airways. but absence of the symptom does not mean that serious lung disease is not present. dyspnea. such as occurs in asthma. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. of the toes) called “clubbing. diffuse 198 .” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). 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. can cause pleurisy. pulmonary embolism. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. The pain disappears when fluid accumulates in the pleural space. Chest pain may be an early symptom of lung disease. a small lung cancer that is not obstructing an airway does not produce shortness of breath. severe chest pain may be caused by the spread of malignant disease to involve the pleura. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. or by a tumour that arises from the pleura itself. such as a mesothelioma. pain of this severity is rare.7 The Respiratory System 7 small alveoli and airways. a condition known as a pleural effusion. Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. Severe. but it is most often associated with an attack of pneumonia. rarely. Some diseases of the lung are associated with the swelling of the fingertips (and. and chest pain—may be added several others. since. A wheeziness in the chest may be heard. Fortunately. In addition.
and some symptoms apparently unrelated to the lung. particularly the small nodes above the collarbone in the neck. Methods of inVestigation Physical examination of the chest remains important. Not infrequently. as may sensory changes in the legs. a 199 . general psychological depression. and lung cancer. a disinclination for physical activity. In some lung diseases. as it may reveal the presence of an area of inflammation. such as mild indigestion or headaches. since a peripheral neuropathy may also be the presenting evidence of these tumours. In the case of lung cancer. A person with active lung tuberculosis or with lung cancer. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints. unusual fatigue. or seemingly minor symptoms as the first indication of disease. this unusual sign may disappear after surgical removal of the tumour. especially in the early stage. Loss of appetite and loss of weight. may be diverse indicators of lung disease. may be conscious of only a general feeling of malaise. the first symptom may be a swelling of the lymph nodes that drain the affected area. Not infrequently. The generally debilitating effect of many lung diseases is well recognized. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. are variable and nonspecific. the patient may feel as one does when convalescent after an attack of influenza. Thus. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease.7 Approaches to Respiratory Evaluation and Treatment 7 fibrosis of the lung from any cause. cerebral signs from intracranial metastases. Because the symptoms of lung disease. a hip fracture from bone metastases. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. for example.
or injected. MRI is useful for imaging the heart and blood vessels within the 200 . The sounds detected with a stethoscope may reveal abnormalities of the airways. because the technique is not well suited to imaging air-filled spaces. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT).7 The Respiratory System 7 pleural effusion. or an airway obstruction. and abnormal breathing patterns. in the case of perfusion scanning. and the perfusion scan allows visualization of the blood vessels in the lungs. In these techniques. Methods of examination include physical inspection and palpation for masses. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. sputum examination for malignant cells is occasionally helpful. tender areas. the lung tissue. 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. in the case of ventilation scanning. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. percussion to gauge the resonance of the underlying lung. a radioactive tracer molecule is either inhaled. or the pleural space. The ventilation scan allows visualization of gas exchange in the bronchi and trachea. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. While the resolution of computerized tomography is much better than most other visualization techniques. and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds.
which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). and the rate of gas transfer across the lung. or the pressure required to inflate it. More complex laboratory equipment is necessary to measure the volumes of gas in the lung. Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. the stiffness of the lung. 201 . By feeding a surgical instrument through a special channel of the bronchoscope. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. and major bronchi. in which workload. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. and gas exchange are compared before. and after exercise. which is often used in field studies. trachea. airflow resistance. total ventilation. physicians can collect fluid and small tissue samples from the airways. Tests of exercise capability. the distribution of ventilation within the lung. during. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. Ventilatory capability can be measured with a peak flow meter. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. are useful in assessing functional impairment and disability.7 Approaches to Respiratory Evaluation and Treatment 7 thorax. Spirometry. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function.
7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. 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. 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). or the transfer of gas between the alveoli and the blood. 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 .
and maximal expiratory flow rate (MEFR). which is measured by a dilution method. and total lung capacity (TLC). expressed in litres of air per minute. functional residual capacity (FRC). breathing movements may also be registered graphically on a spirogram. or capillaries. all the other volumes may be recorded with a spirometer. 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. the resting lung volume. which measure the capacity of the lungs to move air in and out. or air within the chest at the end of a quiet expiration. of the lungs. Chest X-ray X-ray imaging is a valuable diagnostic technique used in medicine. who discovered X-rays in 1895. maximum air volume expelled in a time interval. taken to look for infections such as 203 . One of the most common screening roentgenograms is the chest film. maximum air volume that can be expelled after a maximum inspiration.7 Approaches to Respiratory Evaluation and Treatment 7 volume (RV). air remaining within the chest after a maximal expiration. vital capacity. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. forced expiratory volume (FEV). maximal flow rate of a single expelled breath. volume of a breath. include maximal voluntary ventilation (MVV). air volume within the chest in full inspiration. maximal air volume expelled in 12 to 15 seconds of forced breathing. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. Except for the residual volume. Ventilation tests. This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. tidal volume.
Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. the blockage of one of the pulmonary arteries or of a connecting vessel. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. 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. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. but. thereby narrowing the passageway and hindering the flow of blood. or VQ (ventilation quotient) scan. 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. To track the movement of air. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 . 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. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. unfortunately. For the perfusion part of the scan.
normal air and blood flow are reflected in the even distribution of tracers within the lungs. including angiography. the levels of radioactivity are exceptionally low and pose a very small risk to patients. a mismatch between the two scans is indicative of disease. Nutrient deprivation renders the tissue highly susceptible to death. highlight places within the lungs where air or blood have accumulated abnormally. or areas where the tracers become highly concentrated and therefore produce bright areas in the images. In general. Thus. In both ventilation and perfusion scans. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. the tissues affected will be either oxygen.or blooddeprived. In contrast. Although the tracers used in lung ventilation/perfusion scanning are radioactive. the ventilation and perfusion scans match for a person with healthy lungs. Bronchoscopy Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. The appearance of hot spots. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. and another set of images is taken with the scanner.7 Approaches to Respiratory Evaluation and Treatment 7 with technetium). The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent 205 . If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism. he or she may subsequently undergo more invasive procedures.
Inc.7 The Respiratory System 7 The trachea and major bronchi of the human lungs. 206 . Encyclopædia Britannica.
207 . Bronchoscopy is also employed to remove foreign objects from the airways. 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. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. to deliver certain therapeutic agents directly into the lungs. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways.g. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. which enables large volumes of fluid (e. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. known as a rigid bronchoscope. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. because of their ability to bend and twist.7 Approaches to Respiratory Evaluation and Treatment 7 cough or who are coughing up blood. consists of a metal tube that has a wide suction channel. and to assist in the placement of stents (tubes. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. In addition. There are two types of bronchoscopes. Flexible scopes. blood) to be removed during an examination. 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. they remain superior for specific applications. both flexible and rigid scopes have a channel through which instruments can be passed. The second type of scope..
rigid bronchoscopy. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs. Mediastinoscopy Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. For example. trachea. serving as one of the primary 208 . In most cases. Because the region of the mediastinum contains the heart. causing a condition known as pneumothorax. bleeding subsides without the need for medical intervention. because of the discomfort caused by the device. In addition. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity. including nausea and vomiting. and thymus gland. Bleeding is especially common following biopsy. however. causing them to bleed. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). In contrast. which occurs when the instrument is not sanitized properly.7 The Respiratory System 7 Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. upon waking. necessitates the use of general anesthesia. there are several important risks associated with the bronchoscopy procedure itself. the movement of a bronchoscope through the airways often scratches superficial tissues. which can cause side effects in some people. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. as well as a set of lymph nodes. esophagus.
In cancer staging. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. Most patients recover within several days following mediastinoscopy. flexible instrument—is then passed through the incision and into the space between the lungs. Staging involves the investigation of cells to assess the degree to which cancer has spread. the doctor is able to investigate the surfaces of the various structures. which is performed under general anesthesia.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. A mediastinoscope—a thin. This may also be performed for other tissues in the region that display signs of disease. immediately above the sternum. By carefully maneuvering the scope in the space. light-emitting. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. 209 . The biopsy samples are then investigated for evidence of abnormalities. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. such as abnormal growths or inflammation. During mediastinoscopy. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. particularly for cellular defects associated with cancer and for the presence of infectious organisms. Severe complications— such as bleeding. infection. including computerized axial tomography and positron emission tomography. and the procedure is associated with a very low risk of complications. This step of the procedure is known as mediastinotomy. a surgeon first makes a small incision in the patient’s neck.
One of the conditions frequently dealt with is obstruction of breathing passages.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. There are different methods of treatment employed in respiratory therapy. Chest percussion. In addition. or a fog (as in an oxygen tent or a croup tent). 210 . Oxygen may be administered in controlled amounts to assist laboured breathing. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. performed manually or by means of a handheld percussor or vest. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. mucolytics. 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. each of which may be tailored to a specific disease. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. produces vibrations that help to loosen and mobilize secretions. such as bronchodilators. Medications. adjustment. respiratory therapists are experts in the setup. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. A mixture of helium and oxygen is used to treat some diseases of airway obstruction. and maintenance of mechanical ventilators. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. as in treatment of cystic fibrosis. and antibiotics. hot steam. Therapy may involve the administration of gases for inhalation.
Decongestants are sympathomimetic agents. that are of particular importance in the routine treatment of respiratory illness. and antibiotics. That is. due to the emergence of resistant organisms. and larger arteries respond to some degree. The relative safety and efficacy of these drugs has made them generally reliable medications. thus reducing blood flow to the inflamed areas. the arterioles. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. and thus they are used by many people. decongestants. When administered in nasal sprays or drops or in devices for inhalation. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever.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. although capillaries. veins. they mimic the effects of stimulation of the sympathetic 211 . Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. However. antihistamines. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. decongestants and antihistamines are available over the counter. In countries such as the United States. there are three groups. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. The constricting action chiefly affects the smallest arteries.
The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. One of the chief drugs of the group is epinephrine. inflammation. insomnia. and naphazoline hydrochloride. amphetamine and several derivatives. they must be used repeatedly. however. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. or heart palpitations. which has been used in Chinese medicine for more than 5. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. thereby preventing histaminetriggered reactions under such conditions as stress. results in absorption into the bloodstream. too frequent use. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . an alkaloid originally obtained from the leaves of ma huang. in which epinephrine constricts the blood vessels of the skin. and allergy.7 The Respiratory System 7 division of the autonomic nervous system. following its release from certain large cells (mast cells) within the body.000 years. Ephedrine and other decongestants are made by chemical synthesis. Because none of them has a sustained effect. dizziness. headache. They include phenylephrine hydrochloride. any of several species of shrubs of the genus Ephedra. causing anxiety. The oldest and most important decongestant is ephedrine. The effectiveness of the other decongestants results from their chemical similarity to epinephrine.
Because histamine is involved in the production of some symptoms of allergy and anaphylaxis.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. antihistamines can control certain allergic conditions. compounds that were more potent. Anilinetype compounds. edema. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. Other side effects include gastrointestinal irritation. Persons with urticaria. 213 . blurred vision. more specific. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. The most common side effect in adults is drowsiness. itching. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. subsequently. and certain sensitivity reactions respond well. and most are rendered inactive by monoamine oxidase enzymes in the liver. The first antihistamines were derivatives of ethylamine. Antihistamines are readily absorbed from the alimentary tract. headache. If a patient’s condition does not improve after three days of treatment with antihistamines. and less toxic were prepared. were too toxic for clinical use. Antihistamines are not usually beneficial in treating the common cold and asthma. it is unlikely that he or she will benefit from them. nearly all antihistamines produce undesirable side effects. tested later and found to be more potent. and dryness of the mouth. More than 100 antihistaminic compounds soon became available for treating patients. In 1942. among them hay fever and seasonal rhinitis. The development of these antihistamines dates from about 1937. Used in sufficiently large doses. Nasal irritation and watery discharge are most readily relieved.
such as the tetracyclines. whereas others. and for a sufficient length of time to ensure that the infection is totally eradicated. They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). These drugs are usually administered orally. Antibiotics known as macrolides (e. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. cimetidine (Tagamet) was introduced. act against a broad spectrum of different bacteria. clarithromycin. azithromycin) are particularly effective in the treatment of bacterial respiratory infections.g. Macrolides. at a high enough concentration to be effective (but not cause side effects). but they can be given parenterally. Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. and they are especially important in the treatment of bacterial respiratory infections. in which tissues such as the 214 . erythromycin. Some are highly specific. 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. Antibiotics vary in their range of action.7 The Respiratory System 7 During the 1970s an H2-blocking agent. which inhibit bacterial protein synthesis. Oxygen Therapy The medical administration of oxygen is an important means of treating respiratory disease. Oxygen therapy is used for acute conditions. 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.
however. Some patients may require oxygen administration via a transtracheal catheter. In addition. 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. In emergency situations. a device inserted into the nostrils that is connected by tubing to an oxygen system. For patients affected by chronic lung diseases. known as hyperbaric oxygen therapy (HBOT). home oxygen therapy may be prescribed by a physician. oxygen may be delivered through a face mask or through a nasal cannula.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. such as chronic obstructive pulmonary disease (COPD). HBOT has been promoted as an alternative therapy for certain conditions. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. 215 . In both the hospital and the home settings. These applications are controversial. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). Another form of therapy. 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. portable compressed-gas oxygen cylinder. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. 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. which is inserted directly into the trachea by way of a hole made surgically in the neck.
In the ABG test. Oxygen concentrators. In pulse oximetry. Large stationary and small portable gas cylinders can be used in the hospital or the home. 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. a probe. it is converted to a gas. Oxygen is usually administered in controlled amounts per minute. Oxygen turns to liquid only when it is kept at very cold temperatures. Another form of oxygen storage is in compressed-gas cylinders. and carbon dioxide levels are measured. Stationary and portable oxygen concentrators have been developed for use in the home. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood 216 . a measure known as the flow rate. blood is drawn from an artery. Flow rate is determined based on measurements of a patient’s blood oxygen levels. The stored oxygen can then be used by the patient when needed and is readily replenished. provide a method of storing oxygen at concentrations greater than that occurring in ambient air. which necessitates more-frequent cylinder replacement. as opposed to releasing gas constantly. 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 blood acidity. which can be refilled at pharmacies or by delivery services. 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.7 The Respiratory System 7 There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. When it is released under pressure from cold storage. generally placed over the end of a finger. oxygen. Liquid oxygen can be stored in small or large insulated containers. which draw in surrounding air and filter out nitrogen. Oxygen also can be stored as a highly concentrated liquid.
In general. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. adverse physiological effects may ensue if the flow rate is too high. For example. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. Also. HBOT is associated with an increased risk of barotrauma of the ear. if they are not secured and stored 217 . Likewise. leading to the damage of healthy tissues.7 Approaches to Respiratory Evaluation and Treatment 7 that are carrying oxygen. However. For example. such as with the drug bleomycin. it does not appeal to some patients. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. oxygen therapy does not alter the progression of lung disease. a chronic disorder affecting infants. Bronchopulmonary dysplasia. Excess oxygen flow also can result in conditions such as barotrauma. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. Compressed-gas cylinders present a significant safety hazard in the home as well. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. which can lead to tissue dysfunction and cell death. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. a response that is amplified in the presence of excess oxygen. If oxygen flow rate is too low. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD.
Resuscitation by inducing artificial respiration consists chiefly of two actions: 1. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. can prevent some deaths from drowning. Likewise. which has been found to be more effective than the manual methods used in the past. Artificial Respiration Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering.7 The Respiratory System 7 properly. establishing and maintaining an open air passage from the upper respiratory tract (mouth. strangulation. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. throat. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. lifts the lower jaw forward and upward to open the air passage. clears his mouth of foreign material and mucus. The person using mouth-to-mouth breathing places the victim on his back. and pharynx) to the lungs and 2. choking. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. if applied quickly and properly. 218 . places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. they may cause explosions. or other sources of ignition. Furthermore. Such techniques. suffocation. and electric shock. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. candles. oxygen can readily spread fire. carbon monoxide poisoning.
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.
Once the needle is inserted. Prior to thoracentesis. permitting the victim to exhale. liver. It is most often used to diagnose the cause of pleural effusion. For diagnostic applications. If the victim is a child. the rescuer may cover both the victim’s mouth and nose. 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. as well as to prevent further complications associated with the condition. including heart failure. Thoracentesis Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. and lung infections. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs. and spleen. the abnormal accumulation of fluid in the pleural space. including infectious organisms.7 The Respiratory System 7 and clamps the nostrils. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. including pleural empyema. He then alternately breathes into the victim’s mouth and lifts his own mouth away. such as chest X-rays or computerized axial tomography chest scans. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. such as tuberculosis and pneumonia. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. particles such 220 . including the lungs. In the subsequent thoracentesis procedure. tumours. a needle is inserted through the chest wall and into the effusion site in the pleural space. the results of chest percussion and imaging tests.
which occurs when a needle punctures the lungs. and tumour cells. Thoracentesis is a relatively quick procedure. Experimental compression chambers first came into use around 1860. More serious complications include pneumothorax. coagulopathy). another breathing mixture. Air. generally lasting about 10 to 15 minutes. 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.. tissue injury arising from radiation therapy for cancer. for several hours afterward patients are often observed for the manifestation of adverse effects. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate. Thoracentesis is contraindicated in persons with bleeding disorders (i. Pressures 221 . In its simplest form. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks. However. Minor complications associated with thoracentesis include pain and cough. which are suggestive of mesothelioma or lung cancer. leading to a drop in blood pressure and fainting (syncope). the accumulation of air in the pleural space. and wounds that are difficult to heal. and aberrant stimulation of the vasovagal reaction. also known as a decompression chamber (or recompression chamber). Hyperbaric Chamber A hyperbaric chamber. particularly upon detection of cancerous cells. gas gangrene resulting from infection by anaerobic bacteria.7 Approaches to Respiratory Evaluation and Treatment 7 as asbestos. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness.e. The results of these analyses frequently warrant further diagnostic testing. gas embolism. carbon monoxide poisoning.
which increases oxygen availability to the body in therapeutic treatment. for example. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. In the treatment of carbon monoxide poisoning. 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. or from a combination of the two. In the treatment of decompression sickness.5 to 3 times higher than ordinary atmospheric pressure. 222 . from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen).7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment.
With proper selection of donor organs and proper transplantation technique. which presumably would leave the lungs intact. survival at one year has been reported at 90 percent. the techniques are being pursued aggressively in specialized centres. pulmonary fibrosis. emphysema. 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 . Because transplantation offers the only hope for persons with severe lung disease. 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. many people who die of severe head injuries. for example. 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. Persons severely disabled by cystic fibrosis.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. sarcoidosis. who may be relatively young. but from the late 1970s bilateral lung transplantation had some striking results. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. conclusion In the 21st century. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. often have also suffered lung injury or lung infection.
acquiring genetic mutations that alter their infectious characteristics. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. basic knowledge of the viruses that cause the common cold eluded scientists. Such progress promises to reduce the global mortality of lung cancer. 224 . 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. The negative influence of behaviours such as tobacco smoking on lung function is now well documented. sometimes drastically increasing their ability to infect and cause disease in humans. which are the most frequent cause of the common cold. For decades. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. 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. Influenza viruses circulate globally. with health and environmental concerns at the forefront. However.7 The Respiratory System 7 respiratory system. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. In many countries. in 2009 researchers reported having mapped the genetic codes of rhinoviruses. In fact. mesothelioma. and similar preventable respiratory afflictions.
225 . as well as new treatments. For example. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. 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. As researchers and physicians continue to uncover new information about the human respiratory system.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. 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.
controls the traffic of air and food. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. Act on the larynx as a whole. during the act of swallowing. or transformation of glucose into energy. Also known as a decompression chamber or recompression chamber. functions as a lid to the larynx and. moving it upward or downward.GLOSSARY apnea Cessation of breathing. leaf-shaped flap. 226 . diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. epiglottis Cartilaginous. convection The transfer of heat by movement of a heated fluid such as air or water. glycolysis Fermentation. glottis A sagittal slit formed by the vocal cords. hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. hypercapnia Excess carbon dioxide retention.
227 . pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. length. and as the organ of phonation. resulting in the development of secondary tumours. thereby increasing its spreading and wetting properties. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. and tension of the vocal cords. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. a thin membranous sac encasing each lung. purulent Pus-producing. neuraminidase A glycoprotein on the surface of influenza viruses. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. surfactant Substance that. metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. pleura In humans. when added to a liquid.7 Glossary 7 hypoxia Reduction of oxygen supply to tissues to less than physiological levels. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx. rhinitis Inflammation of the mucous tissue of the nose. reduces its surface tension. paranasal sinuses Cavities in the bones that adjoin the nose.
Berger. The human respiratory system is described in David V. Sullivan (eds. Pack (eds. with vol. (2008).). 4th ed. ed. Christie. The Physiology and Medicine of Diving. The Respiratory System (2003). Corwin Hinshaw and John F. Diagnosis of Diseases of the Chest. 4th ed. Peter T. (1971). Murray. Fraser et al. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. 2nd ed. and Michael P.). HighAltitude Medicine and Pathology. Fishman’s Pulmonary Diseases and Disorders. 1 also available in a 3rd ed. (2001). Sleep and Breathing. Macklem. Control of breathing is described in Murray D.). and Ronald V. Altose and Yoshikazu Kawakami (eds. Physiology of Respiration. Bates. and Robert G. (1977–79). H. Dempsey and Allan I. Control of Breathing in Health and Disease (1999). 228 . (1988). (1993). Elliott (eds. 4th ed. a detailed text on impairment of lung function caused by disease. Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. Bennett and David H. (1995). 2nd ed. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. Hlastala and Albert J. (1995). Fishman and Jack A. 2nd. 2nd ed.BIBLIOGRAPHY Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. Abnormal breathing during sleep is covered by Nicholas A. 4 vol. Regulation of Breathing. Elias.. (1994). The effects of swimming and diving on respiration are detailed in Peter B. Saunders and Colin E..). and Jerome A. 2nd ed.
G. Disorders of the Respiratory System. Churg et al. (1988). Comprehensive texts include Gordon Cumming and Stephen J. 3rd ed. (1994). Respiratory Disorders (1983). Principles of Pulmonary Medicine.). 3 vol. provides a comprehensive overview of pathophysiology as related to clinical syndromes. Pulmonary Diseases and Disorders. Fishman (ed. Respiratory Diseases. Textbook of Respiratory Medicine. Scadding and Gordon Cumming (eds. and Andrew M. and Ian R. Murray and Jay A.). 2nd ed. (1980). Alfred P. See also John F..). Weinberger.7 Bibliography 7 Diseases of the Chest. see also J. 2nd ed. (1981). Scientific Foundations of Respiratory Medicine (1981). (eds. is a general textbook covering diagnosis and treatment of chest diseases. 3rd ed. 4th ed. Steven E. Thurlbeck’s Pathology of the Lung.). 3rd ed. Semple. 229 . 2nd ed. Bateman. Nadel (eds. (2005). (1998). (1980). Cameron and Nigel T. John Crofton and Andrew Douglas. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage.
73. Josef. 169. 166 black lung. 169. 198 bronchioles. 197. 171 antibiotics. 141–144 B barotrauma. 168–169. 42. Georgius. 48 apnea. 134. 214 antihistamines. 113 alkalosis. 208. 184–186 altitude sickness. 152–156. 33–34 bronchiolitis. Paul. 81. 102. 81. 174 Buerger disease. 211. 160–164. 159. 30. 127. 52. 181. 212–214 aortic body. structure of. 111. 96. 187 byssinosis. 211. 118–119 air–blood barrier. 74. 131–133. 75 acidosis. 176. 174–175 C cancer.130–131. 46. 126 arterial gas embolism. 50 Breuer. 111 Adam’s apple. 171 AIDS. 184. 51. 76. 123. 109. 210. 100–102. 38. 33–34 stem. 168. 117. 114. 186. 85 artificial respiration. structure of. 182. structure and function of. 91. 137. 223 bronchitis. 27 adenosine triphosphate (ATP). 164. 111. 94. 205–208 brown lung. 196. 93. 213 atelectasis. 136. 137. 99–100. 30. 153. 34–35 amantadine. 198. 169. 103 anemia. 135. 171–173 asphyxiation. 30. 170–171 Bordet. 124–125. 197 bronchopulmonary dysplasia. 39 alcoholism. 116. 188 bird fancier’s lung. Jules. 64. 77 Agricola. 187 anesthesia. 217 Bert. 169 lung. 86. 175. 159. 107. 52. 184 Actinomyces. 188–189 alveoli. 79–80. structure and function of. 172. 217 bronchoscopy. 175. 122. 209 animals. 127. 92. 49 bronchi. 152. 194 asthma. 112–113. 97. 108.INDEX A acid–base balance. 110. 171–173. 152. 147. 131. 221 asbestosis. 129. 218–220 asbestos. 35. 171. 193 anthracosis. 230 . 28–29 bronchiectasis. 106 bradykinin. 173. 46. 189–192. 115. 75. 103.
133–136. 136. 92. 196. 50. 122. 156–158. 50. abnormal. 98. 44. 145. 78. 80. 151 D decompression sickness. 34 cold. 215. 46. 158 diffusion limitation. 65. 210. 78. 174. 164 coughing blood. 66. 164. 170. 47. 74 goblet cells. 49 high altitudes. 192. 216–217 Hering. 98. 204. Octave. 132 types of. 50. 111. 135. 131. 217 Clara cells. 25. 197. 198 croup. 159. 102. 84. 106. 21. 189–192. 180. 215 carotid body. 144. 60. 182 G gas exchange. 95. 213 cause of. 223 7 E emphysema. 96. 130. 49 Hering-Breuer reflex. 56. 69. 117. 137. 97. 190. 199. 94. 25. 105–106. 211–212 diaphragm. 159. 130. 209. 220. 95. 207 physiology of. John Scott. 88 corticosteroids. 183. 214 diving. 87. 187. 98–99 cystic fibrosis. 145–148. 63. 212 exercise (training). 201 F farmer’s lung. 47. 150 epiglottis. 30. 222 decongestants. 184. 47. 166 fungi. 75. Ewald. 127–129. 108. 27. 85. 147. 218 dyspnea. 93. 168. 187. 94. 88–91. 221 cardiopulmonary resuscitation (CPR). 156. 157–158. 112. 215. 72 diphtheria.7 Index 181. 79–81. 196–197. 193–195. 81 central nervous system disease. 171. 98. 160 HIV. 129. 119 231 . 158. 136–138. 137. 87. 69–72 Gengou. 183 hay fever. 48. 52 Cheyne-Stokes breathing. 177. 84. 130. 188–189. 149. 197. 81. 122. 30 Goodpasture syndrome. 62. 98–99 epiglottitis. 51–52. 106. 201. 106 glycolysis. 143. 186. 115. 81–86. 91. 58–59. 175. 64. common. 213 hemoglobin. 67. 138. 197–198 H Haldane. 52 chloride shift. 191–193 drowning. 190 histamine. 80. 198. 65. 223 eosinophilic granuloma. 132. 137. 98–99 epinephrine. 190. 67 chronic obstructive pulmonary disease (COPD). 221. 182. 211. 86. 122. 183. 161. 64. 75–78.
176. 44. 81–82. 49. 197 development of. 81 mountain sickness. 26–28 Legionnaire disease. 113–114. 127 hygiene. 87. 50 meningitis. 159 congestion of. 26 232 . 110. 99 mediastinoscopy. 93. 141. 178. 177 size of. 91. 139. 87. 110. 221–222 hypercapnia. 126 hypoxemia. 92. 31 transplantation of. 147. 181. 47. 81 aerobic. 221 metabolism. 138. 151. 199 bird flu. 173 cancer of. 127. 215. 156–158. 208 medulla. 198. 209. 138–141. 88. 81 mucoviscidosis. 149. 127. 73–78. 208–209 mediastinum. 190. 204–205 M measles. 99. 45. 94. 38–40 infarction. 74. 198. 163 hydrothorax. 196 laryngitis. 103 H1N1. 52. 76–77. 114–115. 182. 125 hypoventilation. 83 hypersensitivity pneumonitis. 173. 149 influenza. 186–188 I idiopathic pulmonary fibrosis. 221 collapse of. 76 Monge disease. 69. 104 vaccine. 217 hypoxia. 37. 102–105. 117 mesothelioma. 98. 138. 114. 166–167 hyperventilation. 223 lung ventilation/perfusion scan. 50. 103. 70. 96. 199. 55–56. 150. 31. 38. 152–156. 215. René-ThéophileHyacinthe. 122. 95–96 larynx. 171–173. 74. 83. 129. 172. 173. 169. 119 hyperbaric chamber. 145 K kidney. 184–186 hypothyroidism. 204. 167. 94 nerves laryngeal. 214 leukemia. 68. 149. 100 lungs N nephritis. 46–48. 135–136.7 The Respiratory System 7 hookworm. 184 L Laënnec. 144–145. 117. 78 anaerobic. 178. 143. structure and function of. 26. 51–52. 128. 41.
122 function of. 94. 107 penicillin. 129–130. 41. 50 psittacosis. 93 congestion of. 22 irrigation of. 34 pyothorax. 211. 214–218 128. 108–113. 154. 95 shunting. 126–130. 107–108. 180–182 pons. 114. 130. 155. 88. 91.7 olfactory. 93 sinusitis. 69–71 silicosis. 209. 113. 194 pulmonary parenchyma. 91. 91–92. 104 osteoporosis. 88 rimantadine. 128 R Relenza. 23–24 sinus. 220 pneumothorax. 127. 89 structure and function of. 111 parrot fever. 21–24. 103. 198. 47 vagus. 131. 92. 170. 56. 38. 45. 159. 24–25 pickwickian syndrome. 31–32. 128. 203 P parasites. 57. 208. 114 Pott disease. 125. 87. 105–106. 36. 92–94. 50. 149–150. 126 oseltamivir. 92. 103. 107. 106. 160 sleep. 126 pleura. 146. 173. 110 pulmonary alveolar proteinosis. 170 pneumonia. 108. 214 pharynx. 124. 136. structure and function of. 117. 167. 126. 85 nose cilia. 139. 118 prostaglandins. 184. 50 nitrogen narcosis. 189. 198 pleural effusion. 179 rheumatoid arthritis. 164 inflammation of. 107. 178. 104–105 respiratory distress syndrome. 127–129. 87. 137 oxygen therapy. 214 pertussis. 87. 211. 198. 223 scarlet fever. 198 pneumoconiosis. 180. 127. 52–53. 26. 108. 99 Index 7 O obesity. 95. 44 Pontiac fever. 168–169. 91. 221 pollution. 84. 100 rhinoviruses. 122. 152. 139. 141. 33. 172. 179–180 Reynaud disease. 103. 169–170 sinuses. 220 pleurisy. 126. 33. 103 Röntgen. 19. 93. S sarcoidosis. 53. 187 rheumatic fever. 137. 85. 136 233 .Wilhelm Conrad. 208. 214. 164 pharyngitis. 200. 138. 150–151 pulmonary edema. 22.
220–221 thoracic emphyema. 150. 78. 95. 96–98 trench mouth. 178. 97 smell. 103. 111. structure and function of. 105–107 Z zanamivir. 204. 137. 93. 103. 23–24. 136. 175. 114–121. 164. 92. 28–30 tracheitis. 92. 199. 130. 87. 94. 96. 91. 155–156. 182. 53. 27–28 vitamin C. 164. 91. 116. 92. 88. 198. 172. 104–105 234 . false. 192–193 tonsillitis. 138. 118. 170. 92. 97. 94 staphylococci. 107. 91 vocal chords. 128. 133–135. 21. 123. 95. 220 typhoid. 138. 173 Valsalva maneuver. 143. 92 streptococcal bacteria. 81–86 syphilis. 123–124 sore throat. 97 trachea. 106 thoracentesis. 97. 197. 102. 69 vestibular folds. 95 tuberculosis. 97.102. 183. 164 snoring. 99. 103. 94 smoking. 87. 27–28 T Tamiflu. 171. 122. 91. 94–95 tonsils. 146 strep throat. 163. 209 swimming. 93. 214 surgery. 122. 218 sneezing. 108. 33. 97. 92. 106. 104 tetanus. 127–129 thoracic squeeze. 138. 96. 97 V vaccination. 129. 95. 125. 208.7 The Respiratory System 7 smallpox. 131–132. 87. 58 ventilation–blood flow imbalance. 119. 152. 99. 94–95. 56. 199. 25. 153. 53. 109. 110. 171. 124 W whooping cough. 176. 130.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.