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Media Acquisition Kara Rogers: Senior Editor. Production Control Steven Bosco: Director. Britannica. Levy: Executive Editor J.istockphoto. Luebering: Senior Manager Marilyn L. All rights reserved. For a listing of additional Britannica Educational Publishing titles. p. 122. call toll free (800) 237-9932. Inc.) in association with Rosen Educational Services. © www. Encyclopædia Britannica. New York. First Edition Britannica Educational Publishing Michael I. and the Thistle logo are registered trademarks of Encyclopædia Britannica. 159. 196. Distributed exclusively by Rosen Educational Services. © www. 228. Inc. QP121. NY 10010. Biomedical Sciences Rosen Educational Services Heather M. 230: A healthy set of lungs is the powerhouse behind the respiratory system. Rosen Educational Services.E. Rogers.com / nicoolay .istockphoto. 60. Editorial Technologies Lisa S.” Includes bibliographical references and index.R467 2011 612. LLC. Barton: Senior Coordinator. ISBN 978-1-61530-147-8 (library binding) 1. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. 87. LLC 29 East 21st Street.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. Kara. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. Copyright © 2011 Encyclopædia Britannica. Inc. cm.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer.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. I. All rights reserved. Chip Somodevilla/Getty Images On pages 19.(The human body) “In association with Britannica Educational Publishing. 41. -. 226. Respiratory organs—Popular works.
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 .
61 The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration. Circulation. and Metabolism 73 Adaptations 78 High Altitudes 79 Swimming and Diving 81 Chapter 4: Infectious Diseases of the Respiratory System 87 Upper Respiratory System Infections 88 Common Cold 88 Sore Throat 91 Pharyngitis 91 Sinusitis 92 Tonsillitis 94 Lower Respiratory System Infections 95 Laryngitis 95 Tracheitis 96 Croup 98 Infectious Bronchitis 99 Bronchiolitis 100 Influenza 102 Whooping Cough 105 77 .
Psittacosis 107 Pneumonia 108 Legionnaire Disease 113 Tuberculosis 114 Chapter 5: Diseases and Disorders of the Respiratory System 122 Disorders of the Upper Airway 122 Snoring 123 Sleep Apnea 124 Pickwickian Syndrome 126 Diseases of the Pleura 126 Pleurisy 127 Pleural Effusion and Thoracic Empyema 127 Pneumothorax 129 Diseases of the Bronchi and Lungs 130 Bronchiectasis 130 Chronic Bronchitis 131 Pulmonary Emphysema 133 Chronic Obstructive Pulmonary Disease 136 Lung Congestion 138 Atelectasis 141 Lung Infarction 144 Cystic Fibrosis 145 Idiopathic Pulmonary Fibrosis 149 Sarcoidosis and Eosinophilic Granuloma 149 Pulmonary Alveolar Proteinosis 150 Immunologic Conditions of the Lung 151 Lung Cancer 152 Diseases of the Mediastinum and Diaphragm 156 115 123 .
165 167 181 Chapter 6: Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 159 Allergic Lung Diseases 159 Asthma 160 Hay Fever 164 Hypersensitivity Pneumonitis 166 Occupational Lung Disease 167 Silicosis 169 Black Lung 170 Asbestosis and Mesothelioma 171 Respiratory Toxicity of Glass and Metal Fibres 173 Byssinosis 174 Respiratory Toxicity of Industrial Chemicals 175 Disability and Attribution of Occupational Lung Diseases 176 Other Respiratory Conditions 177 Circulatory Disorders 177 Respiratory Distress Syndrome 179 Air Pollution 180 Carbon Monoxide Poisoning 183 Acidosis 184 Alkalosis and Hyperventilation 184 Hypoxia 186 Altitude Sickness 188 Barotrauma and Decompression Sickness 189 Thoracic Squeeze 192 Drowning 193 Chapter 7: Approaches to Respiratory Evaluation and Treatment 196 Recognizing the Signs and Symptoms of Disease 196 .
Methods of Investigation 199 Pulmonary Function Test 202 Chest X-ray 203 Lung Ventilation/Perfusion Scan 204 Bronchoscopy 205 Mediastinoscopy 208 Types of Respiratory Therapy 210 Drug Therapies 211 Oxygen Therapy 214 Artificial Respiration 218 Thoracentesis 220 Hyperbaric Chamber 221 Lung Transplantation 223 Conclusion 223 202 Glossary 226 Bibliography 228 Index 230 219 .
the air is cleansed and moistened before entering the lungs. the centre of the respiratory system. The right lung has 10 airway segments. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. and the left lung has 8 to 10. But there are many treatments to keep the airways free and clear. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. warming. A thin membranous sac known as the pleura covers the lungs. This structure provides humans with the sense of smell while also filtering. Air that passes through the nose travels to the pharynx. Here. 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. The larynx is a hollow tube connected to the top of the windpipe. whether by a viral or bacterial infection or through detrimental habits such as smoking. They pump vital oxygen through airways and into the bloodstream every second of every day. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. After passing through the larynx. also known as the windpipe. air travels through the trachea. It also sheds light on how easily a healthy respiratory system can be damaged. there are numerous nerves and blood vessels. humans could not survive on Earth. the most prominent feature of the lung interior are the many small air passages called 11 T . and moistening inhaled air. Inside the lungs. eventually reaching the region where gas is exchanged. the cone-shaped passageway leading from the mouth and nose to the larynx. Without this ability.7 Introduction 7 he human lungs are amazing feats of nature. However. or voice box. or throat.
is made up of three separate compartments for blood. the oxygenated blood is pumped to the rest of the body. controlled by the brain. The first of these. thereby delivering oxygen and other nutrients to organs distant from the lungs. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. The act of breathing. 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. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. but still keeps them separate. The average adult lung has approximately 300 million alveoli. air. or respiration. the region where oxygen is transferred to the blood and carbon dioxide is removed. is an automatic process. the pulmonary system. through the pulmonary veins. The gas-exchange area. and tissue. The second blood system in the lungs. and to the left atrium of the heart. The bronchial circulation is a vital source of nourishment for the lung tissues.7 The Respiratory System 7 bronchioles. The tissue compartment supports the air and blood compartments and lets them come into close contact. Thus. which look like cells in a honeycomb. which range in diameter from 3 mm (0. comprises the network of blood vessels supporting the conducting airways themselves. which makes exchanging gases easier. through the pulmonary arteries. Lungs also have two distinct blood circulation systems. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 . the bronchial circulation. From the heart. humans and other animals do not need to actively think about breathing in order for it to happen.04 inch). The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli.
there also exist sensors that monitor the muscles that control breathing. Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. during sleep. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. One of the major abdominal muscles involved in breathing is the diaphragm. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. air moves in and out of the lungs in response to pressure changes. In the basic mechanics of breathing. This response represents the body’s attempt to prevent toxins from entering the lungs. In contrast. these receptors constrict the airways and cause breathing to become fast and shallow. The 13 . In addition to the types of sensors described above. 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. During exercise. which are located throughout the body. others respond to chemical changes in the immediate external environment. respectively. metabolic rate and acid levels in muscle tissue increase.7 Introduction 7 abdomen. which functions to move air in and out of the lungs as it contracts and relaxes. 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. When stimulated. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. These effects trigger an increase in respiration rate.
Without oxygen. People who live at high altitudes adapt to this decrease in oxygen availability. the small air spaces in the lungs. The main purpose of respiration is to provide oxygen for the body’s cells.7 The Respiratory System 7 diaphragm is the major muscle that facilitates breathing. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. is a gradual process. acclimatization. transfer carbon dioxide from and add oxygen to blood. Oxygen deprivation. oxygen is present at lower levels than it is at low altitudes. which can lead to death. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. Oxygen is used by cells for the breakdown of nutrients. during vigorous breathing. even for only a few minutes. hiking up during the day and descending down to camp to 14 . The amount of air that the lungs pump changes dramatically depending on external or internal conditions. but it is assisted by a complex assembly of other muscle groups. can cause the brain and the heart to stop functioning. cells are unable to function properly. in which the body works to more efficiently utilize oxygen in the air. The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. However. and metabolism all work together. The pulmonary alveoli. 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. an activity that is necessary to supply energy to the cells and the body. circulation. In adults. At high altitudes. Respiration. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth.
The 15 . as well as bacterial pneumonia. a condition known as tracheitis. Pneumonia also often affects persons with impaired immune systems. In the lower respiratory system. Before antibiotics were widely available. Essentially. in which the body circulates additional blood to the lungs. but the blood leaks into the air sacs. Other common upper respiratory conditions include sore throat and pharyngitis. death is caused by drowning. which can lead to high-altitude pulmonary edema. which can be particularly dangerous in infants and in the elderly. the body’s tissues become deprived of oxygen. many people have their tonsils removed after suffering from chronic tonsillitis. certain viruses and fungi can also cause the disease.7 Introduction 7 sleep at night. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. Inflammation of respiratory tissues can sometimes be severe and chronic. This enables the body to adjust to the decreased availability of oxygen. which can arise as a result of infection. For example. and in the first decade of the 21st century. If these precautions are not taken. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. as climbers make their way up the mountain. it was a leading cause of death. In the 18th and 19th centuries. pneumonia was a widespread and notoriously deadly disease. bacteria can cause inflammation of the trachea. Tuberculosis is another example of a respiratory disease caused by bacteria. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. Although bacteria sometimes cause pneumonia. because these individuals are unable to defend against infectious organisms.
One of the best-characterized inherited conditions is cystic fibrosis. This process leads to the eventual breakdown of respiratory tissues. A severe form of snoring is sleep apnea. Eventually. a strain of influenza virus gives rise to a pandemic. in which the collapse of the airways leads to intermittent stoppages in breathing. snoring is caused by blocked airways. blood vessels in the lungs burst. seasonal respiratory illness that is caused by viral infection. despite extensive research. or large cheese-like masses. headaches. which may be associated with obesity. and stomach pain.” and thus is used to describe diseases of uncertain origin. no cause has been identified. Sleep apnea causes affected individuals to awaken periodically through the night. to form. resulting in the formation of cavities in the lungs. One example is idiopathic pulmonary fibrosis. and the infected person coughs up bright red blood. muscle pains. For example. Many respiratory conditions arise from noninfectious causes. Influenza is a common. Every few decades. Lung cancer can arise as a result of a 16 . The term idiopathic means “of unknown cause. It is a highly contagious disease too. sticky mucus that blocks the airways and the digestive tract. Infection is accompanied by fever. chills. the primary symptom of which is the production of a thick. A respiratory disease of major concern in the world today is lung cancer.7 The Respiratory System 7 tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. Some respiratory diseases are inherited. which caused between 25 million and 50 million deaths worldwide. One of the deadliest influenza pandemics was that of 1918–19. For some diseases of the respiratory system. which results in progressive shortness of breath until a person can no longer breathe.
Today. Construction workers and insulators exposed to asbestos often suffer from asbestosis. however. or white lung disease. it was still considered rare.7 Introduction 7 variety of factors. although tobacco smoking is the primary cause. The best-known occupational lung disease is black lung. Breathing asbestos can also cause the cancerous condition known as mesothelioma. The antiviral agents Tamiflu (oseltamivir) and Relenza (zanamivir) played an important role in treating persons affected by influenza during the H1N1 influenza pandemic of 2009. or work. and even cockroaches.3 million fatalities each year. particularly pneumonia and tuberculosis. Now. more than 7 percent of children and 9 percent of adults suffer from asthma. lung cancer is the leading cause of cancer deaths worldwide. however. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. In addition to vaccines and antivirals. tobacco smoke. which affects coal miners who inhale coal dust for many years. Scientists are constantly researching and developing new and different treatments for respiratory ailments. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. Some respiratory diseases arise as a result of occupational. Many treatments. Breathing problems caused by allergies to environmental conditions are fairly common. There is hope for those who suffer from respiratory diseases and disorders. Doctors first described the symptoms of lung cancer in the mid-19th century. resulting in an estimated 1. factors. most likely resulting from exposure to air pollution. In the early 20th century. Nasal decongestants and antihistamines are examples of commonly used remedies. Several vaccines have been developed to prevent illnesses such as influenza. 17 . have been around for years and are readily available.
A healthy set of lungs is nothing to take for granted. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant. chemotherapy. which can identify mutations that render some lung cancers susceptible to certain drugs. As this book shows. and the consequences of neglecting or damaging that fragile system can be drastic.7 The Respiratory System 7 Lung cancer treatments may consist of surgery. the human respiratory system is a finely tuned feat of engineering. Treatment may also be based on the results of genetic screening. . The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. and radiation.
the pharynx (or throat). or respiration. it is otherwise an automatic process. just at the top of the larynx (or voice box). The respiratory system consists of two divisions: upper airways and lower airways. such as the intrapulmonary bronchi. The lower airway system consists of the larynx. where its delicate tissues are 19 . the design of the respiratory systeM The human gas–exchanging organ. the lung. the bronchioles. These actions encompass not only muscular movements but also cellular and chemical processes. Breathing. the stem bronchi. is fundamental to survival. occurring without our having to think about it. Yet. supporting this process are a number of complex actions that occur within our bodies.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. and the alveolar ducts. and though we possess the ability to consciously control the rate of our breathing. and all the airways that branch extensively within the lungs. the trachea. is located in the thorax (or chest). The upper airway system comprises the nose and the paranasal cavities (or sinuses). as simple as it is for us to inhale and exhale. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. and part of the oral cavity.
Encyclopædia Britannica. protected by the bony and muscular thoracic cage. called conducting airways. carbon dioxide. Inc. 20 .7 The Respiratory System 7 The lungs serve as the gas-exchanging organ for the process of respiration. 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.
through which air may be inhaled or exhaled. and the circulatory system (i. Other elements fundamental to the process of respiration include the blood.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. under the control of the central nervous system. For respiration. the heart and the blood vessels). and it protects against the passage into the lungs of potentially infectious foreign agents. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. is sometimes also considered a part of the upper airways. The filtering process is vital to clearing inhaled air of dust and other debris. the collaboration of other organ systems is essential. and the intercostal muscles of the chest wall play an essential role by generating.. the nasal 21 . the nasal cavity. The diaphragm. as the main respiratory muscle. Morphology of the upper airways The nose. whose bony framework is formed by the ribs and the thoracic vertebrae. In addition to fulfilling a fundamental role in respiration. sinuses. The muscles expand and contract the internal space of the thorax. The Nose The nose is the external protuberance of an internal space. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract.e. such as enabling the sensation of smell. which pumps blood from the heart to the lungs and the rest of the body. The oral cavity. which acts as a carrier of gases. the pumping action on the lung. the structures of the upper respiratory tract also have other important functions.
Correspondingly. The sinuses are located in four different skull bones: the maxilla. middle. the ethmoid sinuses. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. ciliated and secreting cells. Each canal opens to the face by a nostril and into the pharynx by the choana. The paranasal sinuses are sets of paired single or multiple cavities of variable size. The passageways thus formed below each ridge are called the superior. they help keep the weight of the skull within reasonable limits. and sphenoid bones. Most of their development takes place after birth. Its top cell layer. the epithelium. and the sphenoid sinus. The complex shape of the nasal cavity results from projections of bony ridges. Typically. This structural design 22 . and inferior nasal meatuses.7 The Respiratory System 7 septum. The sinuses have two principal functions: because they are filled with air. consists principally of two cell types. the frontal sinus. via the nasolacrimal duct. ethmoid. they are called the maxillary sinus. which is the largest cavity. middle. the mucosa of the nose contains mucus-secreting glands and venous plexuses. The floor of the nasal cavity is formed by the palate. The duct drains the lacrimal fluid into the nasal cavity. the superior. it is also flooding the nasal cavity. frontal. with the lacrimal apparatus in the corner of the eye. from the lateral wall. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also. which is located in the upper posterior wall of the nasal cavity. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. which also forms the roof of the oral cavity. and they serve as resonance chambers for the human voice. and they reach their final size around age 20. and inferior turbinate bones (or conchae). On each side.
About two dozen olfactory nerves convey the sensation of smell from the 23 . In the roof of the nose. The vestibule. the air is dried and cooled. reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. is lined by skin that bears short thick hairs called vibrissae. Inc. the olfactory organ with its sensory epithelium checks the quality of the inspired air.7 Anatomy and Function of the Human Respiratory System 7 Sagittal view of the human nasal cavity. During expiration through the nose. Encyclopædia Britannica. a process that saves water and energy. Two regions of the nasal cavity have a different lining. moisten. and warm the inspired air. preparing it for intimate contact with the delicate tissues of the gas-exchange area. at the entrance of the nose. They clean.
is primarily a passageway for air and secretions from the nose to the oral pharynx. Inc. the nasopharynx. The upper floor. Encyclopædia Britannica. The act of swallowing briefly opens the normally collapsed auditory tubes and allows the middle ears to be aerated and pressure differences to be equalized. The Pharynx For the anatomical description. 24 . It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. the pharynx can be divided into three floors. In the posterior wall of the Sagittal section of the pharynx.7 The Respiratory System 7 olfactory cells through the bony roof of the nasal cavity to the central nervous system.
while the lungs themselves receive the air and facilitate the process of gas exchange. the vessels transporting blood between the heart and the lungs. a cartilaginous.7 Anatomy and Function of the Human Respiratory System 7 nasopharynx is located a lymphatic organ. The epiglottis. which roofs the posterior part of the oral cavity. and lungs. The first two of these provide a canal for the passage of air to the lungs. controls the traffic of air and food. it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx. the diaphragm. Morphology of the lower airways The major structures of the lower airways include the larynx. 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. the vertebral column. trachea. Lying directly above the larynx. It is delimited from the nasopharynx by the soft palate. which is the second–largest hollow space of the body. the pharyngeal tonsil. The lower floor of the pharynx is called the hypopharynx. When it is enlarged (as in tonsil hypertrophy). leafshaped flap. and the sternum (or breastbone) and is separated from the abdominal cavity (the body’s largest hollow space) by a muscular and membranous partition. 25 . it may interfere with nasal respiration and alter the resonance pattern of the voice. during the act of swallowing. and food from the oral cavity is routed to the esophagus directly behind the larynx. Its anterior wall is formed by the posterior part of the tongue. The lungs reside within the thoracic cavity (chest cavity). The cavity is enclosed by the ribs. the great arteries bringing blood from the heart out into general circulation. functions as a lid to the larynx and.
the glottis. The largest cartilage of the larynx. this function can be closely controlled and finely tuned. and as the organ of phonation. Sound is produced by forcing air through a sagittal slit formed by the vocal cords. The pleural cavity is the space. the thyroid cartilage. This portion of the chest membrane is called the parietal pleura. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. interconnected by ligaments and membranes. is made of two plates fused 26 . the two surfaces tend to touch. so called because it exudes a thin fluid. The laryngeal skeleton consists of almost a dozen pieces of cartilage. The chest cavity is lined with a serous membrane.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. This causes not only the vocal cords but also the column of air above them to vibrate. For the precise function of the muscular apparatus. the mediastinum being the space and the tissues and structures between the two lungs. 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. when it occurs. most of them minute. and over part of the esophagus. or serum. Control is achieved by a number of muscles innervated by the laryngeal nerves. as the mediastinal pleura. and the great vessels. The membrane continues over the lung. the heart. where it is called the visceral pleura. the muscles must be anchored to a stabilizing framework. between the parietal and the visceral pleura. As evidenced by trained singers.
7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. the vocal cords span the laryngeal lumen. which has given this structure the common name of Adam’s apple. 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. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. Like the true vocal cords. the arytenoid cartilages. Behind the shieldlike thyroid cartilage. the thyroid notch. Just above the vocal cords. resembling an organ pipe. Viewed frontally. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. they follow its tilting movement. made of elastic tissue. another large cartilaginous piece of the laryngeal skeleton. The transverse axis of the joint allows a hingelike rotation between the two cartilages. the epiglottis is also attached to the back of the thyroid plate by its stalk. with its narrowest width at the glottis. below it is a forward projection. to which it is joined in an articulation reinforced by ligaments. they are also formed by the free end 27 . has a signet-ring shape. At the upper end of the fusion line is an incision. the lumen of the laryngeal tube has an hourglass shape. This mechanism plays an important role in altering length and tension of the vocal cords. Because the arytenoid cartilages rest upright on the cricoid plate. the laryngeal prominence. The cricoid is located below the thyroid cartilage. The cricoid. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. 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. Both of these structures are easily felt through the skin.
The mucosal layer contains mucous glands. moving it upward (e. The right main bronchus has a larger diameter.8 inch) wide. The intrinsic muscles attach to the skeletal components of the larynx itself. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. The Trachea and the Stem Bronchi Below the larynx lies the trachea. an instrument designed for visual inspection of the interior of the larynx. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. and tension of the vocal cords. is oriented more vertically. The practical consequence of 28 . The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. At its lower end. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. the latter can easily be seen from above with the laryngoscope.. This space is called the ventricle of the larynx. one each for the left and right lung. The muscular apparatus of the larynx comprises two functionally distinct groups. the trachea divides in an inverted Y into the two stem (or main) bronchi. length. The extrinsic muscles act on the larynx as a whole. and is shorter than the left main bronchus. during high-pitched phonation or swallowing) or downward.g. The intrinsic muscles act directly or indirectly on the shape. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. The interior of the trachea is lined by the typical respiratory epithelium. the laryngeal space enlarges and forms lateral pockets extending upward. Between the vestibular folds and the vocal cords. Because the gap between the vestibular folds is always larger than the gap between the vocal cords.7 The Respiratory System 7 of a fibroelastic membrane.
The structure of the stem bronchi closely matches that of the trachea. it makes sense to distinguish the relatively thick-walled. In modeling the human airway tree. largely determines the internal lung structure. 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. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. In irregular dichotomy. a peripheral. From a morphological point of view. purely gas-exchanging zone. Functionally. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. purely conducting zone. may range from 11 to 30 generations. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. Individual paths.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. however. 29 . if the trachea is counted as generation zero. and a transitional zone in between. however. the daughter branches may differ greatly in length and diameter. and partly also of the blood vessels penetrating the lung. where both functions grade into one another. however. structural design of the airway tree The hierarchy of the dividing airways. it is generally agreed that the airways branch according to the rules of irregular dichotomy.
the two stem bronchi. this fluid layer is topped by a blanket of mucus of high viscosity. The epithelium is covered by a layer of low-viscosity fluid. gain their stability from their structural integration into the gas-exchanging tissues. rhythmic beat directed outward. moisten. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. Their function is to further warm. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. where they are swallowed. devoid of cartilage. This design can be compared to a conveyor belt for particles. as does the frequency of goblet cells. The last purely conductive airway generations in the lung are the terminal bronchioles. their height decreasing with the narrowing of the tubes. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. Distally.7 The Respiratory System 7 The conducting airways comprise the trachea. After several generations of such respiratory bronchioles. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. In larger airways. Ciliated cells are present far down in the airway tree. the alveoli are so densely packed along the airway that an airway wall 30 . and the bronchioles. In the alveoli. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. the walls of the bronchioles. within which the cilia exert a synchronized. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. and indeed the mechanism is referred to as the mucociliary escalator. the bronchi.
the trachea with the stem bronchi. In the thorax. Medially. Gross Anatomy Together. and nerves enter or leave the lungs. separated from each other by a deep horizontal and an oblique fissure. has only two lobes separated by an oblique fissure. they are connected with the mediastinum at the hilum. a right and a left. a circumscribed area where airways. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. The right lung represents 56 percent of the total lung volume and is composed of three lobes. the esophagus. and inferior lobe. while their apexes extend above the first rib. The parietal pleura and the visceral pleura that line the inside 31 . The right and left lungs are slightly unequal in size. the lungs occupy most of the intrathoracic space. The final generations of the airway tree end blindly in the alveolar sacs. smaller in volume because of the asymmetrical position of the heart. and the thymus gland. blood and lymphatic vessels. the two lungs rest with their bases on the diaphragm. middle. The space between them is filled by the mediastinum. a superior. the lungs Humans have two lung organs. which corresponds to a connective tissue space containing the heart. The left lung. In humans each lung is encased in a thin membranous sac called the pleura. major blood vessels.7 Anatomy and Function of the Human Respiratory System 7 proper is missing. and the airway consists of alveolar ducts. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood.
The presence of pleural recesses form a kind of reserve space. the recesses are partly opened by the expanding lung. Inc. respectively. of the thoracic cavities and the lung surface. costal. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. the parietal pleura can be subdivided into three portions: mediastinal. A thin film of extracellular fluid between the pleurae enables 32 . so the pleural cavity is larger than the lung volume. thus allowing the lung to increase in volume. are in direct continuity at the hilum.7 The Respiratory System 7 Anatomy of the human lungs. and diaphragmatic pleurae. During inspiration. Encyclopædia Britannica. Depending on the subjacent structures. Although the hilum is the only place where the lungs are secured to surrounding structures.
The Bronchi and Bronchioles In the intrapulmonary bronchi. This outer fibrous layer contains. besides lymphatics and nerves. Unlike the lobes. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. Pulmonary Segments The lung lobes are subdivided into smaller units. Furthermore. the arterial supply follows the segmental bronchi. depending on the classification. If air enters a pleural cavity (pneumothorax). the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. Bronchioles are 33 . respiratory movements can be painful. the pulmonary segments. If the serous membranes become inflamed (pleurisy). There are 10 segments in the right lung and 8 to 10 segments in the left lung. 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. These anatomical features are important because pathological processes may be limited to discrete units. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. and breathing is abolished on this side. the lung immediately collapses owing to its inherent elastic properties.7 Anatomy and Function of the Human Respiratory System 7 the lungs to move smoothly along the walls of the cavity during breathing. and the surgeon can remove single diseased segments instead of whole lobes.
the whole wall is formed by alveoli. and non-capillary blood vessels belong to the non-parenchyma. and vice versa. which produce secretions. Distally. On average. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. The respiratory gases diffuse from air to blood. The walls of the bronchioles lack cartilage and seromucous glands. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. while the supplying structures.722 square feet) of internal surface area of the tissue compartment.7 The Respiratory System 7 small conducting airways ranging in diameter from three to less than one millimetre. capable of narrowing the airway. in the last generation. blood. an adult human lung has about 300 million alveoli. and tissue. alveolar sacs. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. until after two to four generations of respiratory bronchioles. through the 160 square metres (about 1. The gas-exchange tissue proper is called the pulmonary parenchyma. lymphatics. Whereas air and blood are continuously replenished. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells. They are polyhedral structures. the frequency of alveolar outpocketings increases rapidly. The Gas-Exchange Region The gas-exchange region comprises three compartments: air. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. with a 34 . The airways are then called alveolar ducts and. conductive airways.
the thin air–blood barrier for gas exchange. the smallest of the blood vessels.7 Anatomy and Function of the Human Respiratory System 7 diameter of about 250 to 300 micrometres. or cell debris originating from cell damage or normal cell death. the alveolar macrophages are derived from the bone marrow. the type II pneumocyte. and open on one side. is common to two adjacent alveoli. A thin. On top of the epithelium. 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. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. whereas type II cells are secretory. covers between 92 and 95 percent of the gas-exchange surface. Before it is released into the airspaces. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing. and their cell bodies abound in granules of various content. called the interalveolar septum. It contains a dense network of capillaries. Type II pneumocytes produce a surface-tension-reducing material. the pulmonary surfactant. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. more cuboidal cell type. alveolar macrophages creep around within the surfactant fluid. partly foreign material that may have reached the alveoli. These granules are the conspicuous ultrastructural features of this cell type. together with the endothelial cells. They are large cells. Ultimately. and a skeleton of connective tissue fibres. squamous cell type. The interalveolar septum is covered on both sides by the alveolar epithelial cells. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. covers the remaining surface. The alveolar wall. the type I pneumocyte. where they connect to the airway. a second. The type I cells form. It contains connective tissue and interstitial 35 .
After numerous divisions. Blood Vessels. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. As a consequence. are much flimsier than systemic arteries of corresponding size. which seem to be endowed with contractile properties. The fibroblasts are thought to control capillary blood flow or. following relatively closely the course of the dividing airway tree. On each side. amorphous ground substance. which have on average a pressure five times lower than systemic arteries. Because intravascular pressure determines the arterial wall structure. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. the pulmonary arteries. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. low in oxygen content but laden with carbon dioxide. alternatively. The oxygenated blood from the capillaries is collected by 36 . and Nerves With respect to blood circulation. Lymphatic Vessels. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. and proper functioning of the lung is severely jeopardized. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks.7 The Respiratory System 7 fluid. and cells (mainly fibroblasts). the lung is a complex organ. This pathological condition is called pulmonary edema. Blood. The connective tissue comprises a system of fibres. is carried from the right heart through the pulmonary arteries to the lungs. an excess of fluid accumulates in the lung tissue and within the airspaces. to prevent the accumulation of extracellular fluid in the interalveolar septa. the respiratory gases must diffuse across longer distances.
The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. The superficial. Finally. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. 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. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. Small bronchial veins exist. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. The interlobular veins then converge on the intersegmental septa.7 Anatomy and Function of the Human Respiratory System 7 venules and drained into small veins. however. Generally. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. The bronchial arteries originate from the aorta or from an intercostal artery. they end several generations short of the terminal bronchioles. called bronchomediastinal trunks. Most of their blood is naturally collected by pulmonary veins. Within the lung and the mediastinum. Lymph drainage 37 . They are small vessels and generally do not reach as far into the periphery as the conducting airways. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. With a few exceptions. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. 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 Respiratory System
paths from the lung are complex. The precise knowledge of their course is clinically relevant, because malignant tumours of the lung spread via the lymphatics. The pleurae, the airways, and the vessels are innervated by afferent and efferent fibres of the autonomic nervous system. Parasympathetic nerve fibres from the vagus nerve (10th cranial nerve) and sympathetic branches of the sympathetic nerve trunk meet around the stem bronchi to form the pulmonary autonomic nerve plexus, which penetrates into the lung along the bronchial and vascular walls. The sympathetic fibres mediate a vasoconstrictive action in the pulmonary vascular bed and a secretomotor activity in the bronchial glands. The parasympathetic fibres stimulate bronchial constriction. Afferent fibres to the vagus nerve transmit information from stretch receptors, and those to the sympathetic centres carry sensory information (e.g., pain) from the bronchial mucosa.
After early embryogenesis, during which the lung primordium is laid down, the developing human lung undergoes four consecutive stages of development, ending after birth. The names of the stages describe the actual morphology of the prospective airways. The pseudoglandular stage exists from 5 to 17 weeks; the canalicular stage, from 16 to 26 weeks; the saccular stage, from 24 to 38 weeks; and finally the alveolar stage, from 36 weeks of fetal age to about 1 ½ to 2 years after birth. The lung appears around the 26th day of intrauterine life as a ventral bud of the prospective esophagus. The bud separates distally from the gut, divides, and starts to grow into the surrounding mesenchyme. The epithelial components of the lung are thus derived from the gut (i.e., they
Anatomy and Function of the Human Respiratory System
are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.
The Respiratory System
The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.
CONTROL AND MECHANICS OF BREATHING
he respiratory system is intimately associated with the brain and central nervous system. Indeed, the diaphragm and the muscles of the chest are innervated by neurons that connect to regions of the brain known as the pons and medulla oblongata. These regions are involved in the control of autonomic nervous activity and therefore regulate internal organs without any conscious recognition or effort. Thus, breathing is an automated function in which nerve impulses sent from the brain stimulate the respiratory muscles to contract, thereby producing the mechanical forces associated with inhalation and exhalation. These impulses give rise to every breath, and in healthy individuals they are sent faithfully for life.
control of breathing
Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. The respiratory rhythm and the length of each phase of respiration are set by reciprocal stimulatory and inhibitory interconnection of these brain-stem neurons. An important characteristic of the human respiratory system is its ability to adjust breathing patterns to changes in both the internal milieu and the external environment. Ventilation increases and decreases in proportion to
the size of the airway. such as the airway narrowing that occurs in an asthmatic attack. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. Mechanoreceptors monitor the expansion of the lung. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. the force of respiratory muscle contraction. In addition. 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. breathing can be 42 . 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. Intercostal muscles inserting on the ribs. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. chewing and swallowing. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. Although the diaphragm is the major muscle of breathing. These same muscles are used to perform a number of other functions. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. abdominal muscles. such as speaking. they also complicate the regulation of breathing. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement.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. and the extent of muscle shortening. and maintaining posture.
com 43 .7 Control and Mechanics of Breathing 7 Singing demands a strong diaphragm to control breath. Shutterstock.
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. in turn they drive cranial motor neurons. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. Neurally. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. allowing the activity of these physiological systems to be coordinated with respiration. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. which supply the diaphragm and other thoracic and abdominal muscles. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation.
This increase in activity. Then the cycle begins again. 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. expiratory neurons discharge and inspiratory neurons are strongly inhibited. post-inspiratory. inspiratory activity is restarted. When the vagus nerves are sectioned or pontine centres are destroyed. is called apneustic breathing. offswitch. which occasionally occurs in persons with diseases of the brain stem. early inspiratory. As the activity of the post-inspiratory neurons subsides. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. but at a much lower level. although in upright humans the lower expiratory intercostal muscles 45 . and expiratory. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons.7 Control and Mechanics of Breathing 7 abruptly. This type of breathing. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. After a gap of a few milliseconds. which produces lung expansion. Offswitch neurons in the medulla terminate inspiration. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. breathing is characterized by prolonged inspiratory activity that may last for several minutes. and gradually declines until the onset of expiratory neuron activity. Mechanically. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity.
or the reduction of oxygen supply to tissues to less than physiological levels (produced. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). which restores partial pressures of oxygen and carbon dioxide to their usual levels. Conversely. by a 46 . cheMoreceptors One way in which breathing is controlled is through feedback by chemoreceptors. 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. too much ventilation depresses the partial pressure of carbon dioxide. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. During sleep and anesthesia. 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. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. As expiration proceeds. Peripheral Chemoreceptors Hypoxia.7 The Respiratory System 7 and the abdominal muscles may be active even during quiet breathing. There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. with exercise). for example. more expiratory intercostal and abdominal muscles contract. Moreover. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. as the demand to breathe increases (for example. and central chemoreceptors in the brain.
may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. the principal arterial chemoreceptors. which. 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. Microscopically. as reflected in the size of carotid body signals. 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). responding more to rapid than to slow changes in the partial pressure of carbon dioxide. stimulates the carotid and aortic bodies. Acetylcholine. and neuropeptides such as enkephalins. The amplitude of these fluctuations. the carotid body consists of two different types of cells. This arterial blood parameter rises and falls as air enters and leaves the lungs.7 Control and Mechanics of Breathing 7 trip to high altitudes). 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. The type II cells are generally not believed to have a direct role in chemoreception. contain electron-dense vesicles. 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. Fine sensory nerve fibres are found in juxtaposition to type I cells. unlike type II cells. The type I cells are arranged in groups and are surrounded by type II cells. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. a branch of the glossopharyngeal nerve. catecholamines. vasoactive 47 .
Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide.7 The Respiratory System 7 intestinal peptide. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. inhaling gases that contain carbon dioxide stimulates breathing. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide. Even if both the carotid and aortic bodies are removed. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. 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. 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 . and substance P. are located within the vesicles. ventilation increases nearly linearly. which then act on the sensory nerve. As the partial pressure of carbon dioxide in arterial blood rises. 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.
Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. Stimulation of these receptors. another receptor in muscles. 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. which excites stretch receptors in the airways. Tendon organs. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. 49 . Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. Generally. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. because they can help maintain tidal volume and ventilation at normal levels. Changes in the length of a muscle affect the force it can produce when stimulated. there is a length at which the force generated is maximal. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. called spindles. The Hering-Breuer reflex is initiated by lung expansion. 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. These receptors are particularly important when lung function is impaired. Receptors.7 Control and Mechanics of Breathing 7 medulla. monitor changes in the force produced by muscle contraction.
These receptors are supplied.7 The Respiratory System 7 which send signals to the medulla by the vagus nerve. like the stretch receptors. The most important function of these receptors. and thus breathing typically becomes lighter. shortens inspiratory times as tidal volume (the volume of air inspired) increases. For example. the body’s metabolic rate slows. When lung inflation is prevented. which inhibits the penetration of injurious agents into the bronchial tree. others (the J receptors) by unmyelinated fibres. by the vagus nerve. When stimulated. 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. and prostaglandins. during sleep. accelerating the frequency of breathing. these receptors constrict the airways and cause rapid shallow breathing. increased levels of oxygen are needed to fuel muscle function. This in turn leads to fluctuations in breathing patterns. Stimulation of irritant receptors also causes coughing. during exercise. However. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. 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. helping to preserve tidal volume. however. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. Variations in breathing Variations in breathing result from changes in metabolic demands in the tissues of the body. bradykinin. 50 . the reflex allows inspiratory time to be lengthened. At the opposite end of the spectrum.
the arterial chemoreceptors. because body temperature rises as metabolism increases.com 51 . thus preserving acid–base homeostasis.7 Control and Mechanics of Breathing 7 Exercise One of the remarkable features of the respiratory control system is that ventilation increases sufficiently to keep the partial pressure of carbon dioxide in arterial blood nearly unchanged despite the large increases in metabolic rate that can occur with exercise. Mechanoreceptors. arterial chemoreceptors. and thermal receptors. Sources of these signals include mechanoreceptors in the exercising limbs. Shutterstock. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide. and thermal receptors all work in concert during exercise to enhance ventilation. A number of signals arise during exercise that can augment ventilation.
It remains unclear. whereas in rapid eye movement sleep. Sleep During sleep. 52 . The effects on ventilatory pattern vary with sleep stage. how these various mechanisms are adjusted to maintain acid–base balance. is called Cheyne-Stokes breathing. 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 mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. In slow-wave sleep. after the physicians who first described it. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. body metabolism is reduced. This rhythmic waxing and waning of breathing. or even apnea (cessation of breathing).7 The Respiratory System 7 The brain also seems to anticipate changes in the metabolic rate caused by exercise. During sleep. breathing is diminished but remains regular. with intermittent periods of apnea. breathing can become quite erratic. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. but it may entail unstable feedback regulation of breathing. but there is an even greater decline in ventilation so that the partial pressure of carbon dioxide in arterial blood rises slightly and arterial partial pressure of oxygen falls. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. however.
occurs most commonly in the elderly. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference.7 Control and Mechanics of Breathing 7 In addition. leading to severe drops in the levels of blood oxygenation. air enters the lungs (inspiration). In some individuals. this intermittent obstruction occurs repeatedly during the night. Because atmospheric pressure remains relatively constant. sleep is of poor quality. and the reduced activity of these muscles during sleep may lead to upper airway closure. When the air pressure within the alveoli exceeds atmospheric pressure. flow is determined by how 53 . air is blown from the lungs (expiration). and in the obese. like the tongue and laryngeal adductors. which increase the likelihood of obstruction. When the air pressure within the alveolar spaces falls below atmospheric pressure. have normal upper airway anatomy. Others. Many of the upper airway muscles. provided the larynx is open. Because arousal is often associated with the termination of episodes of obstruction. in the newborn. portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids. In some persons with sleep apnea syndrome. in males. however. undergo phasic changes in their electrical activity synchronous with respiration. Snoring and disturbed behaviour during sleep may also occur. termed sleep apnea syndrome. the Mechanics of breathing Air moves in and out of the lungs in response to differences in pressure. The condition. and complaints of excessive daytime drowsiness are common. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways.
There is. Encyclopædia Britannica. therefore. A difference in air pressure between atmosphere and lungs is created. less air per unit of volume in the lungs and pressure falls. Inc. forcing air in and out of the lungs.7 The Respiratory System 7 The diaphragm contracts and relaxes. Each small increment of expansion transiently increases the space enclosing lung air. the volume of chest and lungs 54 . much above or below atmospheric pressure the pressure within the lungs rises or falls. Alveolar pressure fluctuations are caused by expansion and contraction of the lungs resulting from tensing and relaxing of the muscles of the chest and abdomen. When the muscles of inspiration relax. and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume.
therefore. then. This negative (below-atmospheric) pressure is a measure. the pleural pressure reflects primarily two forces: 55 . and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. 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. of the force required to keep the lung distended.7 Control and Mechanics of Breathing 7 decreases. 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. its pressure rises above atmospheric pressure. This. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. 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. thereby allowing the lung to separate from the chest at this particular spot. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. A lung is similar to a balloon in that it resists stretch. resulting in flow of air into or out of the lung and establishment of a new lung volume. In summary. 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. lung air becomes transiently compressed.
as by a wound or by a surgical incision. Because the pleural pressure is below atmospheric pressure. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch.7 The Respiratory System 7 1. During inspiration. This additional muscular force is removed on relaxation 56 . The lung– chest system thus acts as two opposed coiled springs. Were it not for the outward traction of the chest on the lungs. the length of each of which is affected by the other. 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. which are in turn stretched inward by the pull of the lungs. When these muscles relax. these would collapse. the additional retraction of lung returns the system to its equilibrium position. thereby further raising the diaphragm and causing forceful expiration. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. the force required to keep the lung inflated against its elastic recoil and 2. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. And were it not for the inward traction of the lungs on the chest and diaphragm. the force required to cause airflow in and out of the lung. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs.
muscular contraction occurs only on inspiration. 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. During ordinary breathing.154 cubic inches) per minute in adults. such as pieces of glass. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. The respiratory pump is versatile. The volume in these circumstances is known as the residual volume. Pressures 57 . 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. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. 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. At total relaxation of the muscles of inspiration and expiration. expiration being accomplished “passively” by elastic recoil of the lung. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). capable of increasing its output 25 times. separated by a film of water.
The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. with no space between the vocal cords). © www .7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. normally reaching 30 litres per minute in quiet breathing.e..8 pounds per square inch) by the so-called Valsalva maneuver—a forceful contraction of the chest and abdominal muscles against a closed glottis (i. can be raised voluntarily to 400 litres per minute. Airflow velocity. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver. The beating of cilia (hairline projections) from cells lining the airways 58 .istockphoto.
Normal lungs. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. 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. however. In fact. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. such adherence occasionally does occur and is one of the dreaded complications of premature births. 59 . 500 millilitres. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. and seven litres. respectively. totaling about 0.
At high altitudes or during activities such as deep-sea diving. the respiratory system. gas exchange Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. The area of the alveolar surface in the adult human is about 160 square metres (1. which is needed to support the functions of the body’s various tissues.722 square feet). 60 . or ¹/¹00 of the diameter of a human hair. in exchange. about 0. 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. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. as well as other organ systems. The oxygen is then distributed by the blood to the tissues.5 micrometre. adapt to variations in atmospheric pressure.CHAPTER3 GAS EXCHANGE AND RESPIRATORY ADAPTATION I nhaled air is rich in oxygen. whereas the carbon dioxide is expelled from the alveoli during exhalation. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and. however. This process of adaptation is necessary to maintain normal physiological function. For inhaled oxygen to reach these tissues. Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane. transfer carbon dioxide to the alveoli.
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.com 61 .
The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. 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. Convection. for example. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. 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. or mass flow. which in turn is responsive to overall body requirements. The performance of the heart and circula- 62 . caused by differing modes of transport in the blood.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. Respiratory gases also move by diffusion across tissue barriers such as membranes. but almost equal quantities of the two gases are involved in metabolism and gas exchange. convection and diffusion. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. The rapidity of circulation is determined by the output of the heart. In a mixture of gases. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. Local flows can be increased selectively. 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 each gas is directly proportional to its concentration. 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 partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). so less than 2 percent of oxygen is transported dissolved in plasma. Most oxygen is bound to hemoglobin. transport of oxygen Oxygen is poorly soluble in plasma.2 ml of oxygen per ml of blood. therefore. liquid portion of blood. the cell-free. which make up 40 to 50 percent of the blood volume in most mammals. The curve representing the content of oxygen in blood at various partial pressures of oxygen. Not all of the oxygen transported in the blood is transferred to the tissue cells.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. Plasma. 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. plays little role in oxygen exchange but is essential to carbon dioxide exchange. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. The amount of oxygen 63 . Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. called the oxygen-dissociation curve. Each iron atom can bind and then release an oxygen molecule. is a characteristic S-shape because binding of oxygen to one iron atom influences the ability of oxygen to bind to other iron sites. a protein contained within red cells. In alveoli at sea level. These systems are present mainly in the red cells. Enough hemoglobin is present in normal human blood to permit transport of about 0.
binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. or pH. This reserve is available to meet increased oxygen demands. Reductions in normal concentrations of hydrogen ions. Although these substances do not bind to hemoglobin at the oxygen-binding sites. and the curve is shifted 64 . a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). 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. carbon dioxide.3-DPG. venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. including hydrogen ions (which determine the acidity. and 2. (Affinity denotes the tendency of molecules of different species to bind to one another. or 2. At rest.) Increases in hydrogen ions. of the blood). Conversely.3-DPG result in an increased affinity of hemoglobin for oxygen.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. Hemoglobin binds not only to oxygen but to other substances as well. as occurs with anemia or extreme exercise.3-DPG decrease the affinity of hemoglobin for oxygen. and the oxygen-dissociation curve shifts to the right.3-diphosphoglycerate (2. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. carbon dioxide. carbon dioxide. and 2. Because of this decreased affinity. with the binding of oxygen. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen.
65 . blood normally remains in the pulmonary capillaries less than a second. The range of body temperature usually encountered in humans is relatively narrow. principally hemoglobin. remains unchanged and is transported dissolved in blood. An increase in temperature shifts the curve to the right (decreased affinity. with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma.7 Gas Exchange and Respiratory Adaptation 7 to the left. Complete elimination would lead to large changes in acidity between arterial and venous blood. enhanced release of oxygen). transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex. The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. to form a compound known as carbamate. so that temperature-associated changes in oxygen affinity have little physiological importance. The remainder is found in reversible chemical combinations in red blood cells or plasma. Temperature changes affect the oxygen-dissociation curve similarly. A small portion of carbon dioxide. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. whereas a decrease in temperature shifts the curve to the left (increased affinity). as occurs at extreme altitude. an insufficient time to eliminate all carbon dioxide. Furthermore. Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. 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. about 5 percent. Some carbon dioxide binds to blood proteins.
) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. Blood acidity is minimally affected by the released hydrogen ions because blood proteins. a relatively weak acid.7 The Respiratory System 7 Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water. essentially. inactivating them. a protein enzyme present inside the 66 . Carbonic anhydrase. (A buffer solution resists change in acidity by combining with added hydrogen ions and. Shutterstock. are effective buffering agents. As carbon dioxide enters the blood. 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 ). especially hemoglobin.
that is. however. then transported to the plasma. while 62 percent exists as bicarbonate in plasma.7 Gas Exchange and Respiratory Adaptation 7 red blood cell. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. Thus. permits the plasma to be used as a storage site for bicarbonate without changing the electrical charge of either the plasma or the red blood cell. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. 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. A reverse sequence of reactions occurs when blood reaches the lung. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. The bulk of bicarbonate ions is first produced inside the cell. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. The simultaneous exchange of these two ions. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change 67 . where the partial pressure of carbon dioxide is lower than in the blood. The change in molecular configuration of hemoglobin that accompanies the release of oxygen leads to increased binding of carbon dioxide to oxylabile amino groups. A few amino sites on hemoglobin are oxylabile. known as the chloride shift. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. Because the enzyme is present only inside the red blood cell. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule.
yet this pool is important. because only free carbon dioxide easily crosses biologic membranes. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 . The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. and almost all blood entering the lungs participates in gas exchange. because of the increased size of inspired breaths. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. In contrast to the cyclic nature of ventilation. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. Between these two events. 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.7 The Respiratory System 7 or binding. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. Under ideal circumstances. not all inspired air participates in gas exchange. 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. In health. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. blood flow through the lung is continuous. most carbon dioxide is transported as bicarbonate or carbamate. 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.
and limitations of diffusion. shunting. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. 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. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. alveoli filled with fluid or inflammatory material). Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. venous blood enters the bloodstream without passing through functioning lung tissue. Because of the differences in oxygen and carbon dioxide transport. In shunting. A reduction in arterial blood oxygenation is seen with shunting. 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. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. impaired oxygen exchange is far more common than impaired carbon dioxide exchange.. ventilation– blood flow imbalance. but the level of carbon dioxide in arterial blood is not elevated even 69 .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.g.
and the composite arterial blood carbon dioxide content remains normal. As noted earlier. 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. As a result.7 The Respiratory System 7 though the shunted blood contains more carbon dioxide than arterial blood. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. the content of carbon dioxide is greater than the normal carbon dioxide content. When blood perfusing the collapsed. which is usually achieved without difficulty. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung. In contrast. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. Blood leaving an unventilated area of the lung has 70 . 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. Because the carbon dioxide–dissociation curve is steep and relatively linear. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal. 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 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.
In alveoli that are overventilated. Overventilated alveoli. Mixture of blood from this healthy portion of the lung (with normal oxygen content) and blood from the abnormal area of the lung (with decreased oxygen content) produces a composite arterial oxygen content that is less than the normal level. Thus. a plateau is reached at the 71 . Inspired air and blood flow normally are distributed uniformly. and each alveolus receives approximately equal quantities of both. which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. In the healthy area of the lung. therefore. alveoli become either overventilated or underventilated in relation to their blood flow. however. 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. reaches a plateau at the normal alveolar partial pressure. The oxygen-dissociation curve. however. in the arterial blood. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. cannot compensate in terms of greater oxygenation for underventilated alveoli because.7 Gas Exchange and Respiratory Adaptation 7 an oxygen content that is less than the normal content. 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. and an increase in blood partial pressure results in a negligible increase in oxygen content. the amount of carbon dioxide eliminated is increased. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and.
however. the greater the reduction in blood oxygenation. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. These factors are usually grouped under the broad description of “diffusion limitation. In disease. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. Carbon dioxide exchange. loss of surface area available for diffusion of oxygen.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. these include increased thickness of the alveolar–capillary membrane. For oxygen. which facilitates carbon dioxide exchange. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. A variety of processes can interfere with this orderly exchange.7 The Respiratory System 7 alveolar partial pressure of oxygen. 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. 72 . and increased ventilation will not increase blood oxygen content. 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. 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 mitochondria. cells set the demand for oxygen uptake and carbon dioxide discharge. Modern cell biology has unveiled the truth behind the metaphor. and metabolism is the key to the functioning of the respiratory system as a whole. Each cell maintains a set of furnaces. a molecule with only two phosphate bonds. For gas exchange that takes place in the lungs. To recharge the molecule by adding the third phosphate group requires energy derived from 73 . 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. through the oxidation of foodstuffs such as glucose. the energetic needs of the cells are supplied. The precise object of respiration therefore is the supply of oxygen to the mitochondria. where. The circulation of the blood links the sites of oxygen use and uptake. the heart was regarded as a furnace where the “fire of life” kept the blood boiling. In antiquity and the medieval period. In the process. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). whose third phosphate bond can release a quantum of energy to fuel many cell processes. circulation. which set the limit for respiration. such as the contraction of muscle fibre proteins or the synthesis of protein molecules.7 Gas Exchange and Respiratory Adaptation 7 interplay of respiration. This involves transport of oxygen from the lung to the tissues by means of the circulation of blood. ATP is degraded to adenosine diphosphate (ADP). The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. circulation. and MetabolisM The interplay of respiration.
will die. 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. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. or even the organism. It begins with 74 . or substrates. whereas they usually have a reasonable supply of substrates in stock. which requires oxygen and involves the mitochondria. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. Because oxidative phosphorylation occurs only in mitochondria. anaerobic glycolysis. In contrast. Oxygen is collected from environmental air. or fermentation. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. because the cells maintain only a limited store of highenergy phosphates and of oxygen. or its need for oxygen. If oxygen supply is interrupted for a few minutes. aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. For any sustained highlevel cell activity. Two pathways are available: 1.7 The Respiratory System 7 the breakdown of foodstuffs. and 2. and since each cell must produce its own ATP (it cannot be imported). the aerobic metabolic pathway is therefore preferable. many cells. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. aerobic metabolism. transferred to blood in the lungs. which operates in the absence of oxygen.
7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. With exercise this rate can be increased more than 10-fold in a normal healthy individual. In the most peripheral airways. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. the demand for ATP and oxygen increases linearly with work rate. but a highly trained athlete may achieve a more than 20-fold increase. a human consumes about 250 ml of oxygen each minute. which is bound to hemoglobin in the red blood cells.5 micrometre) and the surface area of the barrier. Blood also serves as carrier for both respiratory gases: oxygen. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. or. This is accompanied by an increased cardiac output. transport by blood flow. more accurately the metabolic rate of the cells. and carbon dioxide. Metabolism. 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. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. At rest. 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. which is determined by its content of hemoglobin in the red blood cells. and discharge to the cells. sets the demand for oxygen. As more and more muscle cells become engaged in doing work. essentially resulting from a higher heart rate. and by 75 . Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood.
76 . a feature called allometric variation. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. The limit to oxidative metabolism is therefore set by some features of the respiratory system. Muscle can do more work. such as dogs or horses. mainly lactic acid. but it is not straightforward. Then. from the lung to the mitochondria. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. the athletic species in nature. well below interspecies differences. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. based on observations that oxygen consumption rates differ significantly among species. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. oxygen consumption per unit body mass increases as animals become smaller. but beyond the aerobic scope they must revert to anaerobic metabolism. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. For example. with the result that waste products. the aerobic scope can be increased by training in an individual. have an aerobic scope more than twofold greater than that of other animals of the same size. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. this is called adaptive variation. Consequently. accumulate and limit the duration of work.7 The Respiratory System 7 increased ventilation of the lungs. Furthermore. 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. because of the complexity of the system. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. Much has been learned from comparative physiology and morphology.
7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. Mitochondria set the demand for oxygen. For example. the muscle cells make more mitochondria. This difference arises from a phenomenon known as adaptive variation. in all types of variation. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. In training. 77 . Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system. cardiac output is augmented by increasing heart rate. If energy (ATP) needs to be produced at a higher rate. the mitochondria increase in proportion to the augmented aerobic scope.com Within the aerobic scope the adjustments are caused by functional variation. Shutterstock.
In the cases of swimming and diving. the lung lacks this capacity to adapt. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. It appears. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. In the case of adaptation to high altitudes. the lung may well constitute the ultimate limit for the respiratory system.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. which determines the volume of blood that can be pumped with each stroke. If this proves true. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. the blood vessels. at the last step of aerobic metabolism. or volume to augment their capacity when energy needs increase. the structure of the alveoli in the lungs. whereas the mitochondria. rate. the levels of hemoglobin in the blood. The issue of peripheral versus central limitation is still under debate. 78 . however. the blood. such as in training. But. 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. mainly the heart. 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. whose capacity to pump blood reaches a limit. and the heart can increase in number. beyond which oxidative metabolism cannot be increased by training.
both in the ambient air and in the alveolar spaces of the lung. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. Barry C. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. This very fall poses the major respiratory challenge to humans at high altitude. Indigenous mountain species such as the At high altitudes. such as cattle. 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. whether undertaken deliberately or not.7 Gas Exchange and Respiratory Adaptation 7 High Altitudes Ascent from sea level to high altitude has well-known effects on respiration. which heighten the partial pressure of oxygen at all stages. Humans and some other mammalian species. Bishop/National Geographic/Getty Images 79 . which.
the carotid bodies enlarge but become less sensitive to the lack of oxygen. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. 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. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. and. such as 2. where oxygen is needed for the ultimate biochemical expression of respiration. the size of muscle fibres decreases. which also shortens the diffusion path of oxygen. on the other hand. As the oxygen deprivation persists. the carotid bodies. With a prolonged stay at altitude. which increases the amount of oxygen transported to the tissues. exhibit an adaptation that is heritable and has a genetic basis. 80 . In addition. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages.7 The Respiratory System 7 llama. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. thought to enhance oxygen perfusion of the lung apices. from the alveolar spaces in the lung to the mitochondria in the cells. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. Diffusion of oxygen across the alveolar walls into the blood is facilitated. as capillary density is increased. the tissues develop more blood vessels. which takes the form of deeper breathing rather than a faster rate at rest.3DPG. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. attached to the division of the carotid arteries on either side of the neck. 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.
Nevertheless. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. or benign tumour. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the 81 . Their hemoglobin has a high oxygen affinity. Other physiological changes are also observed. A chemodectoma. They do not develop small muscular blood vessels or an increased blood pressure in the lung. This disease is characterized by greater levels of hemoglobin. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. After living many years at high altitude. and their carotid bodies remain small. alpaca. all vertebrates. after the Peruvian physician who first described it. exhibit a set of responses that may be called a “diving reflex.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. Human respiration requires ventilation with air. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells.7 Gas Exchange and Respiratory Adaptation 7 Indigenous mountain animals like the llama. In contrast to acclimatized humans. including humans. Swimming and Diving Fluid is not a natural medium for sustaining human life after the fetal stage. these indigenous. 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. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. sometimes called Monge disease. some highlanders lose this acclimatization and develop chronic mountain sickness. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude.
Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath. 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. and this danger is greatly increased if the swimmer descends to depth. When the accumulated carbon dioxide at last forces the swimmer to return to the surface. many of them unique in human physiology. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. but it cannot provide an equivalent increase in oxygen. the absolute pressure. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. however. Unconsciousness may then occur in or under the water. Hyperventilation can be dangerous. At the depth of a diver. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. But this apparent advantage introduces additional hazards.7 The Respiratory System 7 same time that a diver is breathing from an independent gas supply. as sometimes happens in snorkeling. Two factors are involved. Hyperventilation. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. and consciousness remains unimpaired. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. Most hazards result from the environmental pressure of water. which is 82 . The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. but the oxygen content of the blood concurrently falls to unusually low levels.
Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. 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 use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. The increased work of breathing. The other factor. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). is the vertical hydrostatic pressure gradient across the body. often with the formation of bubbles. and their subsequent elimination from. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. the increased density of the respiratory gases. is one factor. This may be compounded by an increased inspiratory content of carbon dioxide. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. rather than cardiac or muscular performance. and the consequences of the uptake of respiratory gases into. the blood and tissues of the diver. the levels of inspired oxygen are 83 . More commonly. Hypoxia may result from failure of the gas supply and may occur without warning. is the limiting factor for hard physical work underwater. 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. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body.7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. Alveolar oxygen levels can also be disturbed in diving.
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. The use of hydrogen. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels. In mixed-gas diving. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. provides a greater respiratory advantage for deep diving.640 feet) in the sea and more than 680 metres (2. which in a mixture with less than 4 percent oxygen is noncombustible.5 bar (“surface equivalent value” = 150 percent). At a partial pressure greater than 1. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. 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. approximately in proportion to the reciprocal of the square root of the increasing gas density. like an anesthetic. has the additional advantage of providing a breathing gas of lesser density.2 and 0.7 The Respiratory System 7 increased. At the extreme depths now attainable by humans— some 500 metres (1. High values of end-tidal carbon dioxide with 84 . Oxygen in excess can be a poison. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic.5 bar. it may cause the rapid onset of convulsions.
a condition that. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). which represents the net effect of the external pressures and the effects of chest buoyancy. This is a major cause of death among divers.7 Gas Exchange and Respiratory Adaptation 7 only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. or it may be effectively greater. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. possibly extending into the pericardium or into the neck. in which case more blood will be shifted into the thorax. Also. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. More seriously. has proved useful in designing underwater breathing apparatuses. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). places the diver at great risk. resulting in less intrathoracic blood volume. Failure to exhale 85 . The concept of a hydrostatic balance point within the chest. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. And whatever the orientation of the diver in the water. the expanding gas may rupture alveolar septa and escape into interstitial spaces. Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. if it occurs underwater. Unless vented.
which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure. Inadequacy of diver decompression. even from depths as shallow as 2 metres (6.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. 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. 86 . 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.
infectious diseases. 87 . Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. requiring patient hospitalization. whereas lower respiratory infections include laryngitis. However. and may be highly contagious. with this division occurring at the anatomical level of the larynx. and molds. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues. Examples of severe lower respiratory infections include croup. pharyngitis. whether of the upper or lower respiratory tract. upper respiratory infections include the common cold.CHAPTER4 INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM I nfectious diseases are among the most common conditions affecting the human respiratory system. In most cases. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. sinusitis. various types of pneumonia. These diseases may be caused by a variety of agents. bacteria. however. and any condition of the bronchi and lungs. including viruses. can be effectively treated with prescription antimicrobial drugs. tracheitis. as considered here. and tonsillitis. Some conditions can cause extensive lung damage. Thus. Legionnaire disease. resulting in patient isolation. and tuberculosis.
an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. The cold is caught from exposure to infected people. pharynx. respiratory syncytial viruses. 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. usually one to four days. In other cases. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. The feeling was originally believed to have a cause-and-effect relationship with the disease. Incubation is short. Rhinoviruses. People can carry the virus and communicate it without experiencing any of the symptoms themselves. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. including parainfluenza. and may cause secondary infections in the eyes or middle ears. but this is now known to be incorrect. are the most frequent cause. Some of these infections may resolve on their own. chilled wet feet. and the 88 . sometimes spreads to the lower respiratory structures. not from a cold environment. however. and tonsils are frequently the site of both acute and chronic infections. with little or no medication.7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses. influenza. More than 200 agents can cause symptoms of the common cold. and reoviruses. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract. or drafts. The viruses start spreading from an infected person before the symptoms appear.
7 Infectious Diseases of the Respiratory System 7 spread reaches its peak during the symptomatic phase. the clear fluid often changing to a thick. Symptoms may include sneezing. Diagnosis of a cold is usually made by medical history alone. Cold symptoms vary from person to person. inflammation of the nose (rhinitis). There is usually no fever. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. The usual duration of the illness is about five to seven days. but it is possible to take a culture for viruses. but in the individual the same symptoms tend to recur in succeeding bouts of infection. This fluid acts to dilute the virus and clear it from the nose. sore throat. It may result from the greater amount of time spent indoors. The incidence of colds peaks during the autumn. which respond by pouring out streams of clear fluid. Once a virus becomes established on the respiratory surface of the nose. Young children can contract between three and eight colds a year. and minor epidemics commonly occur throughout the winter. thereby setting up sneezing. usually coming into contact with the infectious agents in day care centres or preschools. and nasal discharge. Symptoms abate as the host’s defenses increase. which increases the likelihood of close contact with those persons carrying cold viruses. yellow-green fluid that is full of the debris of dead cells. a second method of expelling the virus. but lingering cough and postnasal discharge may persist for two weeks or more. There is no effective antiviral agent available for the common 89 . The nasal discharge is the first warning that one has caught a cold. fatigue. If the virus penetrates more deeply into the upper respiratory tract. The sensory organs in the nose are stung by the inflammatory reaction. its activities irritate the nose’s cells. chills. but the reason for this incidence is unknown. Coughing can be dry or produce amounts of mucus. headaches.
fatigue.7 The Respiratory System 7 Usually. but it can comprise sneezing. the common cold does not involve a fever.com 90 . rhinitis. and nasal discharge. Shutterstock. chills. sore throat. headaches.
and the tonsils may secrete pus and become swollen. as are antiseptic gargles. One of the greatest medical controversies in the past few decades has concerned the efficacy of vitamin C (ascorbic acid) in the prevention or treatment of the common cold. fungi. uvula. and tonsils. Therapy consists of treating the symptoms: relieving aches. For a viral sore throat. administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. the throat reddens. The illness can be caused by bacteria. Inflammation usually involves the nasopharynx. a result of irritation by foreign objects or fumes. mycoplasmas. Generally. treatment is aimed at relieving symptoms. soft palate. and nasal congestion. Sore Throat Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). A sore throat may be a symptom of influenza or of other respiratory infections.7 Infectious Diseases of the Respiratory System 7 cold. which typically subside after one week. antibiotics are often effective. Infection by 91 . In many studies. and parasites and by recognized diseases of uncertain causes. In treating nonviral sore throat. Pharyngitis Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. fever. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. viruses. or a reaction to certain drugs. 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.
usually with penicillin. syphilis. nausea. headache. sometimes in children there are abdominal pain. Viral pharyngitis infections also occur. If a diagnosis of streptococcal infection is established by culture.7 The Respiratory System 7 Streptococcus bacteria may be a complication arising from a common cold. Chronic cases caused by irritants in the environment or by 92 . Lymphatic tissue in the pharynx may also become involved. 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). but the other symptoms may persist for another two to three days. and irritability. and the cause of pharyngeal inflammation can be determined by throat culture. diphtheria. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. extremely sore throat that is felt during swallowing. however. and sore throat that last for 4 to 14 days. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. Diagnosis is established by a detailed medical history and by physical examination. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. A number of other infectious diseases may cause pharyngitis. a pustulant fluid on the tonsils or discharged from the mouth. and meningitis. Purulent (pus-producing) sinusitis can occur. swelling of lymph nodes. appropriate antibiotic therapy. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. and a slight fever. is instituted. Within approximately three days the fever leaves. including tuberculosis. They cause fever. headache. requiring treatment with antibiotics.
Following a common cold. Streptococcus pneumoniae. including surgery. but the adjacent mouth and nose have a varied bacterial flora. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. and sinus tenderness. persons with sinusitis are usually found to have an elevation in body temperature. 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. headache. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. On physical examination. 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. and many other penicillin-sensitive anaerobes. The organisms usually involved are Haemophilus influenzae. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. keeping the sinuses clean. Common symptoms include facial pain. and fever following previous upper respiratory viral illness. Under normal conditions. It may also be caused by allergy to agents 93 .7 Infectious Diseases of the Respiratory System 7 impaired immune systems may require more extended treatment. infection can be established. Normally the middle ear and the sinuses are sterile. The origin of acute sinus infection is much like that of ear infection. Staphylococcus aureus. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. When ciliary function is damaged. nasal discharge. Streptococcus pyogenes. If the infection persists.
If antibiotic therapy or repeated lavage do not alleviate the condition. The infection may extend upward into the nose. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. evidenced by tonsillar enlargement. and sometimes headache. The 94 . The treatment includes bed rest until the fever has subsided. and ears or downward into the larynx. malaise. Tonsillitis Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. such as fungi or pollen. and enlarged lymph nodes on both sides of the neck. difficulty in swallowing.7 The Respiratory System 7 in the environment. trachea. and bronchi. and warm throat irrigations or gargles with a mild antiseptic solution. Repeated acute infections may cause chronic inflammation of the tonsils. with or without heart involvement. obstructed breathing. fever. usually hemolytic streptococci or viruses. In severe cases endoscopic surgery may be necessary to remove obstructions. The infection lasts about five days. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. isolation to protect others from the infection. and swollen lymph nodes in the neck. resulting in a peritonsillar abscess. loss of smell. repeated or persistent sore throat. purulent nasal discharge. Locally. Pain is not a feature of chronic sinusitis. sinuses. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. The symptoms of chronic sinusitis are a tendency to colds. virulent bacteria may spread from the infected tonsil to the adjoining tissues. The symptoms are sore throat.
It becomes swollen and filled with blood. diphtheria. Scarlet fever. lower respiratory systeM infections Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. or syphilitic. involving long-term antimicrobial therapy. In diphtheria the tonsils are covered with a thick. and trench mouth may also produce acute tonsillitis. Simple laryngitis is usually associated with the common cold or similar infections. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. in order to prevent potentially disabling damage to lung tissue. pneumonia. steam. adherent membrane. Usually the mucous membrane lining the larynx is the site of prime infection. and contains many 95 . tuberculous. or sulfur dioxide can also cause severe inflammation. Nonbacterial agents such as chlorine gas. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. diphtheritic. the infectious disease tuberculosis. is associated with a high rate of death in infants and the elderly. Likewise. with a grayish membrane that wipes off readily. For example. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. which is a major cause of lung disease globally. whitish. secretes a thick mucous substance.7 Infectious Diseases of the Respiratory System 7 treatment in this case is surgical removal (tonsillectomy). Thus. in trench mouth. Laryngitis is classified as simple. Laryngitis Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection.
fibrin (blood clotting protein). sores or mucous patches can form. When the epiglottis. shorten the vocal cords. There may be eventual destruction of the epiglottis and laryngeal cartilage. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. Most conditions that affect the trachea are bacterial or 96 . tissue destruction is followed by healing and scar formation. and suffocation may result. Tracheitis Tracheitis is an inflammation and infection of the trachea. The wall of the larynx may thicken and become inflamed. In the second stage of syphilis. It may cause a membrane of white blood cells. they may consolidate at the vocal cords and cause an obstruction there. becomes swollen and infected by influenza viruses. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. small lumps of tissue that project from the surface. and diseased skin cells to attach to and infiltrate the surface mucous membrane. which closes the larynx during swallowing. The mucous membrane becomes dry and covered with polyps. As the disease advances to the third stage. A similar type of membrane covering can occur in streptococcal infections.7 The Respiratory System 7 inflammatory cells. the larynx can become obstructed. and produce a permanent hoarseness of the voice. The scars can distort the larynx. alcoholism. leaving ulcers on the surface. When looser portions of this false membrane become dislodged from part of the larynx. Tubercular nodule-like growths are formed in the larynx tissue. Syphilitic laryngitis is one of the many complications of syphilis. Chronic laryngitis is produced by excessive smoking. The bacteria die after infecting the tissue. or overuse of the vocal cords.
fatigue. The mucous glands may become swollen. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. Common bacterial causes of acute infections are pneumococci. Infections may last for a week or two and then pass. and syphilis all afflict the trachea. they do not cause significant damage to the tissue unless they become chronic. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. Chronic infections recur over a number of years and cause progressive degeneration of tissue. In smallpox. such as those that occur on the external skin. and the walls thicken because of an increase in elastic and muscle fibres. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. Typhoid causes swelling and ulceration in the lymph tissue. Generally. Degenerated tissue is eventually replaced by a fibrous scar tissue. and staphylococci. sulfur dioxide. form in the mucous membrane. Syphilis forms lesions that erode the 97 . Irritants such as heavy smoking and alcoholism may invite infections. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. Diphtheria usually involves the upper mouth and throat. pustules and ulcers. Blood vessels increase in number. but the trachea may also be attacked. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. The walls of the trachea during chronic infection contain an excess of white blood cells. Acute infections occur suddenly and usually subside quickly. hemorrhages. tuberculosis. Intense blood congestion. smallpox.7 Infectious Diseases of the Respiratory System 7 viral infections. although irritants like chlorine gas. and swelling of the mucous membrane lining the trachea. Neisseria organisms. streptococci. and degeneration of the tracheal tissue can occur. and small polyplike formations occasionally grow. The infections produce fever. Diphtheria.
or inflammation around the trachea. making it necessary for the patient to sit and lean 98 . Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. and they strike most frequently in late fall and winter. is a more serious condition that is often caused by Haemophilus influenzae type B. Such infections are most prevalent among children younger than age three. Viral infections are the most common cause of croup. hospitalization may be necessary. inflammation occurs around the bronchial tree. It is most often caused by an infection of the airway in the region of the larynx and trachea. Generally. there is obstruction at the opening of the trachea. hoarseness. The symptoms are caused by inflammation of the laryngeal membranes. and difficult breathing. Because of the marked swelling of the epiglottis. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. spasms of the laryngeal muscles. It is characterized by marked swelling of the epiglottis. the onset of viral croup is preceded by the symptoms of the common cold for several days. In cases of severe airway obstruction. The onset is usually abrupt. the most frequent being those with the parainfluenza and influenza viruses.7 The Respiratory System 7 tissue. Some cases result from allergy or physical irritation of these tissues. In some cases. Croup Croup is an acute respiratory illness of young children that is characterized by a harsh cough. and can cause thickening and stiffening of the spaces between the cartilage. also called epiglottitis. with high fever and breathing difficulties. Epinephrine and corticosteroids have also been used to reduce swelling of the airway. Bacterial croup.
7 Infectious Diseases of the Respiratory System 7 forward to maximize the airflow. Children with epiglottitis require prompt medical attention. influenzae. organisms do enter the airways and initiate a sudden and rapid attack. preferably by inserting a tube down the windpipe. 99 . ammonia. it is often part of the common cold and is a common sequel to influenza. It is most frequently caused by viruses responsible for upper respiratory infections. 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. Acute bronchitis can also be caused by bacteria such as Streptococcus. whooping cough. and measles. particularly in people who have underlying chronic lung disease. Patients are given antibiotics. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. Infectious Bronchitis Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). Under certain circumstances. which generally relieve the inflammation within 24 to 72 hours. however. resulting usually in a relatively brief disease called acute infectious bronchitis. Epiglottitis generally strikes children between ages three and seven. In addition. Under ordinary circumstances. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. Therefore. An artificial airway must be opened. or organic solvents. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. through which air passes into the lungs.
Bronchiolitis probably occurs to some extent in acute viral disorders. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. is a long-standing. acute exacerbations of infection are associated with further damage to small airways. and particularly in infections with respiratory syncytial virus. bronchodilators. particularly in children between ages one and two. but it normally clears spontaneously. an acute bronchiolitis episode is followed by a chronic obliterative condition. in whom such a syndrome may follow the acute exposure. Steam inhalation. discussed in a later chapter. repetitive condition. or this may develop slowly over time. with complete healing in all but a very small percentage of cases. In addition to patients acutely exposed to gases. Bronchiolitis Bronchiolitis refers to inflammation of the small airways. In isolated cases. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. In adults. 100 . Another form of bronchitis. and expectorants will usually relieve the symptoms. called chronic bronchitis. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability. though there is little doubt that in most patients with chronic bronchitis. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal.7 The Respiratory System 7 Treatment of acute bronchitis is largely symptomatic and of limited benefit. In some cases the inflammation may be severe enough to threaten life. This pattern of occurrence has only recently been recognized. which results in protracted and often permanent damage to the bronchial mucosa.
is characteristically not followed by acute symptoms. A chest radiograph shows patchy inflammatory change. but a short cough and progressive shortness of breath may not be evident for hours. An inflammation around the small airways. 101 . These develop some hours later. Monty Rakusen/Cultura/Getty Images Exposure to oxides of nitrogen. known as a respiratory bronchiolitis. after blasting underground. which may occur from inhaling gas in silos.7 Infectious Diseases of the Respiratory System 7 Welding in enclosed spaces often results in exposure to oxides of nitrogen. Symptomatic recovery may mask incomplete resolution of the inflammation. or in fires involving plastic materials. and the lesion is an acute bronchiolitis. is believed to be the earliest change that occurs in the lung in cigarette smokers. when the victim develops a short cough and progressive shortness of breath. when welding in enclosed spaces such as boilers.
7 The Respiratory System 7 although it does not lead to symptoms of disease at that stage. though the highest incidence of the disease is among children and young adults. Symptoms associated with respiratory tract 102 . Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. The inflammation is probably reversible if smoking is discontinued. The flu may affect individuals of all ages. A diffuse headache and severe muscular aches throughout the body are experienced. with sudden and distinct chills. In three to four days the temperature begins to fall. and the person begins to recover. together with varying degrees of soreness in the head and abdomen. 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. and a generalized feeling of weakness and pain in the muscles. often accompanied by irritation or a sense of rawness in the throat. after which the onset of symptoms is abrupt. chills. and it is generally more frequent during the colder months of the year. and muscle aches. The incubation period of the disease is one to two days. is an acute viral infection of the upper or lower respiratory tract that is marked by fever. Influenza Influenza. and trachea. by such means as inhalation of infected droplets resulting from coughing and sneezing. bronchial tubes. As the virus particles gain entrance to the body. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. The temperature rises rapidly to 38–40 °C (101–104 °F). also known simply as the flu (or grippe). fatigue.
the standard treatment remains bed rest. routine immunization in healthy people is also recommended. and is caused in most of those cases by complications such as pneumonia or bronchitis. ingestion of fluids. a very serious illness. Other than this. However. and yearly vaccination may be recommended.7 Infectious Diseases of the Respiratory System 7 infection. A newer category of drugs. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. as well as a strain of virus known as influenza type B. Death may occur. However. In order to prevent humaninfecting bird flu viruses from mutating into more 103 . these drugs inhibit influenza A. viral resistance to these agents has been observed. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. thereby reducing their effectiveness. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). It is recommended that children and teenagers with the flu not be given aspirin. and the use of analgesics to control fever. as treatment of viral infections with aspirin is associated with Reye syndrome. These viruses are produced in chick embryos and rendered noninfective. usually among older people already weakened by other debilitating disorders. was introduced in the late 1990s. Protection from one vaccination seldom lasts more than a year. 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. particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. become more prominent and may be accompanied by lingering feelings of weakness. the neuraminidase inhibitors. such as coughing and nasal discharge.
S. a glycoprotein on the surface of influenza viruses. Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. the drug decreases the release of virus from infected cells. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. Zanamivir is given by inhalation only. increases the formation of viral aggregates. Inc. If taken within 30 hours of 104 . Through the inhibition of neuraminidase. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. increases the formation of viral aggregates. Oseltamivir is effective when administered within two days of symptom onset. known as H1N1. has developed resistance to oseltamivir. zanamivir decreases the release of virus from infected cells.S. There is evidence that the most common subtype of influenza type A virus.7 The Respiratory System 7 dangerous subtypes. and decreases the spread of the virus through the body. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. and decreases the spread of the virus through the body.based pharmaceutical company Hoffman–La Roche. Oseltamivir can be given orally. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. Oseltamivir is marketed as Tamiflu by the U. 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.
Centers for Disease Control and Prevention (CDC) (Image Number: 2121) 105 . or “whoop. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. can prevent influenza infection in some adults and children. isolated and coloured with Gram stain. the causative agent of whooping cough. zanamivir can shorten the duration of the illness.7 Infectious Diseases of the Respiratory System 7 the onset of influenza. Whooping cough is caused by the bacterium Bordatella pertussis. Zanamivir.” The coughing ends with the expulsion of clear. is an acute. highly communicable respiratory disease. or pertussis. Whooping Cough Whooping cough. sticky mucus and often with vomiting. when taken once daily for 10 to 28 days. Bordetella pertussis.
and convalescent—which together last six to eight weeks. but the periods between coughing paroxysms are comfortable. the illness progresses through three stages—catarrhal. 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. It was first called the Bordet-Gengou bacillus. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. In 1906 at the Pasteur Institute. paroxysmal. Beginning its onset after an incubation period of approximately one week. In the paroxysmal state. During the convalescent stage there is gradual recovery. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. with bulging eyes. and pertussis) vaccine. variable in duration but commonly lasting four to six weeks. The infected person may appear blue. Complications of whooping cough include pneumonia. The disease was first adequately described in 1578. tetanus. and a low-grade fever. it confers active immunity against whooping cough to children. About 100 years later. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. and still later Bordetella pertussis. slowed or stopped breathing. red eyes. Whooping cough is worldwide in distribution and among the most acute infections of children. undoubtedly it had existed for a long time before that. later Haemophilus pertussis. and occasionally convulsions and indications of brain damage. and be dazed and apathetic. with a short dry cough that is worse at night. there is a repetitive series of coughs that are exhausting and often result in vomiting. Catarrhal symptoms are those of a cold. ear infections.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. Now included in the DPT (diphtheria.
ducks. The association between the human disease and sick parrots was first recognized in Europe in 1879. also known as ornithosis (or parrot fever). Treatment includes erythromycin. and another booster is given when the child is between four and six years old. from which the disease is named). turkeys. because the disease is much less severe when it occurs in older children. occurred in 12 countries of Europe and America. and sometimes the use of an oxygen tent is required to ease breathing. pigeons. Psittacosis Psittacosis. 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. Strict regulations followed concerning 107 . an antibiotic that may help to shorten the duration of illness and the period of communicability. especially if they have been vaccinated in infancy. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. and the United States. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. the causative agent was revealed.7 Infectious Diseases of the Respiratory System 7 protection. and geese are the principal sources of human infection. Later vaccinations are in any case thought to be unnecessary. Sedatives may be administered to induce rest and sleep. attributed to contact with imported parrots. although a thorough study of the disease was not made until 1929– 30. England. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. when severe outbreaks. parrots and parakeets (family Psittacidae. During the investigations conducted in Germany.
or irradiation. and an elevated respiratory rate. viruses more commonly play a part in weakening the lung. Fungal pneumonia can develop very rapidly and may be fatal. inhalation of foreign particles. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. Although viral pneumonia does occur. The typical duration of the disease is two to three weeks. but the most common causes are bacteria. can cause pneumonia. Infected turkeys. including viruses and fungi. Many organisms. and convalescence often is protracted. In humans psittacosis may cause high fever and pneumonia. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. but in humans it can be fatal if untreated.7 The Respiratory System 7 importation of psittacine birds. Other symptoms include chills. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. because of impaired immunity. weakness. thus inviting secondary pneumonia caused by bacteria. have reduced resistance to 108 . in particular species of Streptococcus and Mycoplasma. but penicillin and the tetracycline drugs reduced this figure almost to zero. but it usually occurs in hospitalized persons who. Before modern antibiotic drugs were available. the case fatality rate was approximately 20 percent. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. head and body aches. ducks. Psittacosis usually causes only mild symptoms of illness in birds. Pneumonia Pneumonia is an inflammation and solidification of the lung tissue as a result of infection. or geese have caused many cases among poultry handlers or workers in processing plants.
In some cases. caused by Streptococcus pneumoniae. 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. humidifiers. the illness may become very severe. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract.7 Infectious Diseases of the Respiratory System 7 infection. The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection.g. As the disease progresses. and difficulty in breathing. when inhaled by previously healthy individuals. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. and recovery generally occurs in a few weeks. Sputum discharge may contain flecks of blood. coughing becomes the major symptom. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the 109 . and it is sometimes fatal. Pneumonia can also occur as a hypersensitivity. Contaminated dusts. smoke inhalation). however. can sometimes cause fungal lung diseases. especially in hospitalized patients. Treatment is with specific antibiotics and supportive care. and animal excreta or to chemical or physical injury (e. particularly in elderly people and young children. These fluids provide an environment in which the bacteria flourish. cough.. or allergic response. chest pain. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing. to agents such as mold. is the single most common form of pneumonia.
although epidemics can occur. or nerves. Most outbreaks of this disease are confined to families. and psittacosis. Other bacterial pneumonias include Legionnaire disease. caused by Mycoplasma pneumoniae. Another bacterium. small neighbourhoods. it does not invade the deeper tissues—muscle fibres. 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. few cases beyond age 50 are seen. Symptoms of 110 . an extremely small organism.7 The Respiratory System 7 lungs. although it has little ability to infect the lungs of healthy persons. Usually the organism does not invade the membrane that surrounds the lungs. Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. an atypical infectious form. M. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. and influenza viruses. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. causing bleeding into the air spaces. caused by Legionella pneumophilia. parainfluenza. Mycoplasmal pneumonia. or institutions. Klebsiella pneumoniae. which leads to the further release of pneumolysin. usually affects children and young adults. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. elastic fibres. but it does sometimes inflame the bronchi and alveoli.
or other chronic diseases. and skin testing is included in the initial examination of patients with lung problems. or dust storms. these patients experience fever with chills. and low-grade fever. and wood pulp may cause similar illnesses. These pneumonias may occur following exposure to moldy hay or sugarcane. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. and malaise. parakeets. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. all of which contain the fungus Actinomyces. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered.7 Infectious Diseases of the Respiratory System 7 these pneumonias include runny nose. A more insidious form of hypersensitivity pneumonia is 111 . Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. Tuberculosis should always be considered a possibility in any patient with pneumonia. and doves may develop manifestations of hypersensitivity pneumonia. In addition. people exposed to rats. pigeons. maple logs. AIDS. all of which may subside in a day if there is no further exposure. particularly if the patient was recently exposed to excavations. room humidifiers. backyard swimming pools. muscle pain. usually followed by respiratory congestion and cough. Other fungi found in barley. Diagnosis is established by physical examination and chest X-rays. headache. cough. and air-conditioning ducts. Nonbacterial pneumonia is treated primarily with supportive care. decreased appetite. old sheds or barns. the prognosis is excellent. In general. shortness of breath. gerbils. Initially.
Treatment consists of removing the patient from the offending environment. or.) Recovery is usual unless too great an area of lung tissue is involved. for example. Infections with fungi such as 112 . Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. and specific laboratory tests. and may prove fatal. weight loss. are difficult to treat. before organ transplantation to reduce the rate of rejection). Scar tissue forms as a result of the presence of the oil. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. it had been known that if the immune system was compromised by immunosuppressive drugs (given. it may come from the body itself when the lung is physically injured.7 The Respiratory System 7 associated with persistent malaise. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. less often. known as lipoid pneumonia. Ordinarily no treatment is necessary. capable of causing invasive pneumonic lesions in the setting of reduced immunity. Diagnosis is established by medical history. and cough. Oil that is being swallowed may be breathed into the respiratory tract. Such infections are a major cause of illness in these patients. Pneumonia in Immunocompromised Persons For some years prior to 1980. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. fever. physical examination. This type of disease. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. and supportive care. bed rest.
the first symptoms of Legionnaire disease are general malaise and headache. Potable water and drainage systems are suspect. but not uniformly. The largest known outbreak of Legionnaire disease. 29 of them fatally. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. Coughing. Although it is fairly well documented that the disease is rarely spread through person-to-person contact. military veterans’ organization. followed by high fever.S. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. as is water at construction sites. Legionnaire Disease Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. the exact source of outbreaks is often difficult to determine. confirmed in more than 300 people. 113 . 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. in 2001. and occasionally some mental confusion is present. shortness of breath. Typically. occurred in Murcia. often accompanied by chills. Although healthy individuals can contract Legionnaire disease. Spain. and abdominal distress are common. a U. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. at a Philadelphia hotel where 182 Legionnaires contracted the disease.7 Infectious Diseases of the Respiratory System 7 Candida also occur. pleurisy-like pain. pneumophila in droplets into the surrounding atmosphere.
Blood vessels also can be eroded by the advancing disease. Treatment for Legionnaire disease is with antibiotics. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. In most forms of the disease. causing the infected person to cough up bright red blood. an influenza-like illness characterized by fever. at which time improved health and hygiene brought about a steady decline in its mortality rates. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. During the 18th and 19th centuries. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. represents a milder form of Legionella infection. coma. L. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. Mycobacterium tuberculosis. this cycle of infection can lead to severe pneumonia. Since the 114 . pneumophila enters the lungs. Pontiac fever. However. the macrophage dies and bursts open. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis. L. Indeed. the bacillus spreads slowly and widely in the lungs.7 The Respiratory System 7 Once in the body. and muscle pain. headache. “consumption.” as it was then known. and death. In some cases. pneumophila. Tuberculosis Tuberculosis is an infectious disease that is caused by the tubercle bacillus. Eventually.
the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 . The prevalence of the disease has increased in association with the HIV/AIDS epidemic. it continues to be a fatal disease continually complicated by drug-resistant strains. Today. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. In addition.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. in less-developed countries where population is dense and hygienic standards poor. 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. tuberculosis remains a major fatal disease. but in areas with poor hygiene standards. Fox Photos/Hulton Archive/Getty Images 1940s.
The Course of Tuberculosis The tubercle bacillus is a small. coughing. cheeselike (caseous) in appearance. sometimes involving the use of five different agents. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. sometimes called latent 116 . in which can be found many bacilli. the primary infection often heals without causing symptoms. rod-shaped bacterium that is extremely hardy. Infections with these strains are often difficult to treat and require the use of combination drug therapies. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. and a small scar in the lung may be visible by X-ray. but most of the visible manifestations of tuberculosis. nodular tubercles. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. are conglomerations of tubercles. and the infected person acquires a lifelong immunity to the disease. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. The bacilli are quickly sequestered in the tissues. Minute droplets ejected by sneezing. are surrounded by immune cells. In this condition. There the bacilli become trapped in the tissues of the body.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. A tubercle usually consists of a centre of dead cells and tissues. from barely visible nodules to large tuberculous masses. it can survive for months in a state of dryness and can also resist the action of mild disinfectants. Individual tubercles are microscopic in size. In otherwise healthy children and adults. and finally are sealed up in hard. A skin test taken at any later time may reveal the earlier infection and the immunity.
Tubercular lesions 117 . most commonly in the upper portion of one or both lungs. In the lung. an alarming symptom. before the advent of specific drugs. bones and joints. These symptoms do not subside. and bladder. This lesion may erode a neighbouring bronchus or blood vessel. the affected person is not contagious. and immunocompromised adults (organ transplant recipients or AIDS patients. once the bacilli enter the bloodstream. a highly fatal form if not adequately treated. with lack of energy. the patient may have chest pain from pleurisy. weight loss. causing the patient to cough up blood (hemoptysis). This causes a condition known as pulmonary tuberculosis. and persistent cough. the primary infection may spread through the body. releasing viable bacilli into the bloodstream. and there may be blood in the sputum. the elderly. causing miliary tuberculosis. In some cases the infection may break into the pleural space between the lung and the chest wall. Fever develops. From the blood the bacilli create new tissue infections elsewhere in the body. skin. for example). though most affected people now recover.7 Infectious Diseases of the Respiratory System 7 tuberculosis. this disease was always fatal. Eventually. genital organs. including the lymph nodes. however. the cough increases. The onset of pulmonary tuberculosis is usually insidious. In fact. usually with drenching night sweats. or collection of fluid outside the lung. they can travel to almost any organ of the body. kidneys. causing a pleural effusion. sometimes after periods of time that can reach 40 years or more. and the general health of the patient deteriorates. intestines. the original tubercles break down. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. In some cases. a highly infectious stage of the disease. An infection of the meninges that cover the brain causes tuberculous meningitis. Particularly among infants.
is characterized by softening and collapse of the vertebrae. kansasii. If the milk is ingested raw. and scarring. The amount of lung tissue available for the exchange of gases in respiration decreases. Tuberculosis of the spine. causing large areas of destruction.7 The Respiratory System 7 may spread extensively in the lung. is the cause of bovine tuberculosis. bovis is transmitted among cattle and some wild animals through the respiratory route. M. often resulting in a hunchback deformity. and this. bovis readily infects humans. finally eroding through the skin as a chronic discharging ulcer. Other Mycobacterial Infections Another species of bacteria. a great preference for bones and joints. or Pott disease. M. and mycobacteria other than tuberculosis (MOTT). has led to the disappearance of bovine tuberculosis in humans in many countries. where it causes caseation of the node tissue (a condition formerly known as scrofula). atypical mycobacteria. marinum. M. and M. ulcerans. and it is also excreted in milk. avium (or M. 118 . The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. aviumintracellulare). This group includes such Mycobacterium species as M. where it causes destruction of tissue and eventually gross deformity. It shows. bovis may spread into the bloodstream and reach any part of the body. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. along with the systematic identification and destruction of infected cattle. M. however. From the gastrointestinal tract. M. The node swells under the skin of the neck. Pasteurization of milk kills tubercle bacilli. cavities. M. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. bovis.
stained with a compound that penetrates the organism’s cell wall. in which a sputum specimen is smeared onto a slide. in the urine. or in the cerebrospinal fluid. An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. and other organs only in people whose immune systems have been weakened. atypical mycobacterial illnesses are common complications of HIV infection. lies in preventing exposure to infection. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. The primary method used to confirm the presence of bacilli is a sputum smear. possibly in isolation until they are noninfectious. is composed of specially weakened tubercle bacilli. The main hope of ultimate control. known as BCG vaccine. and examined under a microscope. tuberculosis. it causes a local reaction. It has been widely used in some countries with success. individuals at risk 119 . Among AIDS patients. In many developed countries.7 Infectious Diseases of the Respiratory System 7 These bacilli have long been known to infect animals and humans. and this means treating infectious patients quickly. its use in young children in particular has helped to control infection in the developing world. but the prognosis is usually poor owing to the AIDS patient’s overall condition. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. Injected into the skin. A vaccine. in gastric washings. but they cause dangerous illnesses of the lungs. Treatment is attempted with various drugs. lymph nodes. however. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. which confers some immunity to infection by M. If bacilli are present. tuberculosis for several years.
These drugs are often used in various combinations with other agents. such as ethambutol. 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. making the patient sick again. These drugs may be given daily or two times per week.7 The Respiratory System 7 for tuberculosis. the surviving bacilli will become resistant to several drugs. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. Historically. If subsequent treatment is also incomplete. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. If a patient does not continue treatment for the required time or is treated with only one drug. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. As a result. surgery is rarely needed. 120 . of bed rest and surgical removal of useless lung tissue. treatment of tuberculosis consisted of long periods. ethambutol. and pyrazinamide. Today. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). such as health care workers. but complete cure requires continuous treatment for another four to nine months. with early drug treatment. rifampicin. The patient is usually made noninfectious quite quickly. bacilli will become resistant and multiply. or rifapentine. pyrazinamide. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. in order to avoid the development of drug-resistant bacilli. often years.
it has proved successful in controlling tuberculosis.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. or capreomycin. In 1995. Instead of taking daily medication on their own. amikacin. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. Aggressive treatment using five different drugs. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. 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. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. MDR TB is treatable but is extremely difficult to cure. in part to prevent the development and spread of MDR TB. such as kanamycin. In addition. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). 121 . Although some patients consider DOT invasive.
emphysema. and in many cases therapy may include not only the administration of medications but invasive surgery as well. diseases of the larynx. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. trachea. and diseases of the mediastinum and diaphragm. Conditions affecting these tissues may 122 . ranging from inherited genetic mutations to smoking to trauma. and nasopharynx are all susceptible to disease. bronchial tree. sinuses. and disease in one region frequently leads to involvement of other parts. palate. Treatment for this group of conditions is similarly varied. 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. T diseases of the upper airway The nose. and lungs. diseases of the pleura. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect. Important examples of diseases and disorders of the respiratory system include sleep apnea. Although these divisions provide a general outline of the ways in which diseases may affect the lung. The causes of the various diseases and disorders are diverse. Thus. 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. and cystic fibrosis.
com / Stephanie Horrocks 123 . 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.e.7 Diseases and Disorders of the Respiratory System 7 result from a number of different causes. a potentially life-threatening condition. © www .istockphoto. loud interrupted snoring can indicate sleep apnea. Snoring is more common in the elderly because the loss of tone in the oropharyngeal Although snoring bears the brunt of many jokes. which necessitates breathing through the mouth. It is often associated with obstruction of the nasal passages. Snoring Snoring is a rough. cancer).
which involves characteristics of both obstructive and central apneas. Children’s snoring usually results from enlarged tonsils or adenoids. central. which is the most common form and involves the collapse of tissues of the upper airway. It is also more common in men than in women. airway collapse is eventually terminated by a brief awakening. such as neck size. Whatever the cause. Thus. In men shirt size is a useful predictor. In obstructive sleep apnea (OSA). repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. with the likelihood of OSA increasing 124 . or body-mass index. The word apnea is derived from the Greek apnoia. Loud interrupted snoring is a regular feature of sleep apnea.” There are three types of sleep apnea: obstructive. the condition has a strong association with certain measures of obesity. body weight. and it occurs most often in obese persons. at which point the airway reopens and the person resumes breathing. Obstructive sleep apnea is most often caused by excessive fat in the neck area. meaning “without breath.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx. In addition. a common and potentially lifethreatening condition that generally requires treatment. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. and mixed. snoring is always associated with mouth breathing and can be corrected by removing obstructions to normal nasal breathing or by altering sleeping position so that the affected individual does not lie on his back.
which uses a mask (facial or nasal) during sleep to blow air into the upper airway. Although CPAP does not treat the condition itself. Sleep disturbance may cause difficulty concentrating. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. However. Treatment typically involves continuous positive airway pressure (CPAP). and increase irritability. The risk returns to normal after treatment. The condition is also more common in patients with a set-back chin (retrognathia). which can be resolved only by weight loss or treatment of underlying conditions. though surgery is seldom recommended.5 inches). with many patients describing sleep as unrefreshing. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. and insulin resistance.7 Diseases and Disorders of the Respiratory System 7 with a collar greater than about 42 cm (16. hypertension. 125 . including ischemic heart disease. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents. worsen short-term memory. The most common symptom of OSA is sleepiness. such as hypothyroidism or tonsillar enlargement. it does prevent airway collapse and thus relieves daytime sleepiness. it is less certain that these diseases are caused by OSA. the magnitude of the increased risk is the subject of some debate but is thought to be between three. Other causes of the condition include medical disorders. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. with the resumption of breathing usually described as a gasp or a snort.and sevenfold.
The elevated pressure stresses the right ventricle of the heart. Finally. (By some definitions. thus increasing pressure in the vessels that supply the lungs. excessive fluid accumulates throughout the body (peripheral edema). to be obese is to exceed one’s ideal weight by 20 percent or more.7 The Respiratory System 7 Pickwickian Syndrome Pickwickian syndrome. Because of inadequate removal of carbon dioxide by the lungs. levels of carbon dioxide in the blood increase. oxygen in the blood is also significantly reduced. Individuals who have pickwickian syndrome often complain of slow thinking.) This condition often occurs in association with sleep apnea. leading to respiratory acidosis. ultimately causing right heart failure. The pleural membranes of the 126 . The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. in the space known as the pleural cavity. especially beneath the skin of the lower legs. who showed some of the same traits. Low blood oxygen causes the small blood vessels entering the lungs to constrict. diseases of the pleura The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. also known as obesity hypoventilation syndrome. an extremely obese person would exceed the optimum weight by a much larger percentage. is a complex of respiratory and circulatory symptoms associated with extreme obesity. and fatigue. In more severe instances. 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. drowsiness.
There are many causes of 127 . is an inflammation of the pleura. also called pleuritis. may occur many years after inhalation of asbestos fibres. and treatment of the underlying disease. little or no abnormal fluid accumulates in the pleural cavity. Pleurisy may be characterized as dry or wet. a cancer of the pleura. Pleurisy is commonly caused by infection in the underlying lung and. Because the pleura is well supplied with nerves. the membranes that line the thoracic cavity and fold in to cover the lungs. fluid evacuation. Pleural Effusion and Thoracic Empyema Pleural effusion. a partial or occasionally complete collapse of the lung. by diffuse inflammatory conditions such as lupus erythematosus. including tissues of the neck and head. rarely. Pleurisy Pleurisy. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. or hydrothorax. Treatment of pleurisy includes pain relief. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. pleurisy can be very painful. Mesothelioma. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. In wet pleurisy. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. This causes spontaneous pneumothorax. is an accumulation of watery fluid in the pleural cavity. In dry pleurisy. fluids produced by the inflamed tissues accumulate within the pleural cavity.7 Diseases and Disorders of the Respiratory System 7 lungs are also vulnerable to perforation and spontaneous rupture. enabling air to enter the pleural cavity.
Under certain conditions. infection within the pleural cavity. The presence of both air and pus inside the pleural cavity is known as pneumothorax.7 The Respiratory System 7 pleural effusion. and the presence of fluid as ascertained by a chest X-ray. including pneumonia. If symptoms of pleural effusion develop. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. doxycycline. such as malignant disease of the pleura (i. 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. Thoracic empyema may be characterized by fever. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. coughing. a tube is inserted through the chest wall into the pleural space to drain the fluid.e. Treatment is directed at drainage of small amounts of pus through 128 . and fluid that seeps from the lungs places additional stress on the dysfunctioning heart. As the inflammation heals. This condition is often the result of a microbial. It may also be caused by a lung abscess or some forms of tuberculosis. tuberculosis. Large pleural effusions can cause disabling shortness of breath. air may get into the pleural cavity. shortness of breath. tissue adhesions obliterate the pleural space. and weight loss.. When the bronchial tree is involved in the infection. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. or pyothorax. and the spread of a malignant tumour from a distant site to the pleural surface. usually bacterial. thereby preventing the accumulation of more fluid. and bleomycin. mesothelioma). The accumulation of pus in the pleural cavity is known as thoracic empyema.
Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. chest compression during cardiopulmonary resuscitation (CPR). and tension pneumothorax. or thoracoscopy (closed-lung biopsy). air and pressure accumulate within the chest. blood 129 . As a result. or medical procedures. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. There are three major types of pneumothorax: traumatic pneumothorax. spontaneous pneumothorax. which may then collapse. after which air is sucked through the opening and into the pleural sac. gunshot) or other injuries to the chest wall. Antibiotics are used to treat the underlying infection. the heart. 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. such as high-pressure mechanical ventilation. in tension pneumothorax air that becomes trapped in the pleural space cannot escape. with each breath the patient inhales. Pneumothorax Pneumothorax is a condition in which air accumulates in the pleural space. In contrast to traumatic pneumothorax and spontaneous pneumothorax. When the lung on the affected side of the chest collapses. lung infection. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath.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.
consciousness. It consists of a dilatation of major bronchi. In some cases. In some cases. In fact. which enables the lung to reexpand. may be present in childhood. clubbing (swelling of the fingertips and. occasionally. and airways are pushed to the centre of the chest. thereby compressing the other lung. and breathing that in turn may lead to shock and death.7 The Respiratory System 7 vessels. including bronchiectasis and cystic fibrosis. a catheter connected to a vacuum system is required to re-expand the lung. Whereas several diseases of the bronchi and lungs. This procedure allows air to escape from the chest cavity. diseases of the bronchi and lungs Diseases of the bronchi and lungs are often associated with significant impairments in respiration. Bronchiectasis Bronchiectasis is believed to usually begin in childhood. The bronchi become chronically infected. This leads to decreases in blood pressure. of the toes) may occur. possibly after a severe attack of pneumonia. The disease may also develop as a consequence of airway obstruction or of undetected (and 130 . others may require surgery to prevent recurrences. many of these conditions are associated with irreversible lung damage. Most pneumothoraxes can be treated by inserting a tube through the chest wall. While small pneumothoraxes may resolve spontaneously. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. and excess sputum production and episodes of chest infection are common.
The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air. For example. or of organic substances such as hay dust. Bronchiectasis may also develop as a consequence of inherited conditions. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants.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. many of whom. now reach adult life.” without serious implications. Chronic Bronchitis The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough. who would formerly have died in childhood. medications to dilate the airways and to relieve pain. due to an increase in size and number of mucous glands lining the large airways. have helped control pulmonary infections and have markedly improved survival in affected persons. This common condition is characteristically produced by cigarette smoking. and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. significant quantities of mucus are coughed up in the morning. In some countries chronic bronchitis is caused by daily 131 . 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. of which the most important is the familial disease cystic fibrosis. Management of the condition includes antibiotics to fight lung infections. These therapies. enzyme therapy to thin the mucus. such as parts of plastic toys. in addition to others. After about 15 years of smoking.
though the rate of progression generally slows. By the time this occurs. All these changes together. Unfortunately. is severely compromised.7 The Respiratory System 7 inhalation of wood smoke from improperly ventilated cooking stoves. drugs to suppress paroxysmal coughing may be necessary. Smoking-related chronic bronchitis often occurs in association with emphysema. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. as measured by the velocity of a single forced expiration. It is not clear what determines the severity of these changes. Some people can smoke for decades without evidence of significant airway changes. though these produce the dominant symptom of chronic sputum production. whereas others may experience severe respiratory compromise after 15 years or less of exposure. Occasionally. but they must be used sparingly because they can be addictive and because expectoration is necessary. Because the damage to the bronchial tree is largely irreversible. For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. in a cigarette smoker. The changes are not confined to large airways. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. the coexistence of these two conditions is known as chronic obstructive pulmonary disease. can lead to disturbances in the distribution of ventilation and perfusion in the lung. treatment is mainly symptomatic. ventilatory ability has usually been declining rapidly for some years. Of primary importance is 132 . The mucus-producing cough will subside within weeks or months and may resolve altogether. consisting of expectorants and bronchodilators. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. the ventilatory ability of the patient. if severe enough.
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
particularly if severe enough to warrant hospital admission. either bacterial or viral. which causes increased lung volume and manifests as breathlessness. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation).000 people in the United Kingdom and roughly 119. Exacerbations are triggered by infection. Frequent exacerbations. which gives rise to symptoms of bronchitis. Therefore. Although primarily a lung disease.000 people in the United States die from COPD. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). it is increasingly recognized that COPD has secondary associations. and the burning of certain fuels in poorly ventilated areas. tobacco-related condition. including muscle weakness and osteoporosis. Coughing up blood is not a feature of COPD and when present raises concern about a second. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. particularly lung cancer. are not always required. which is replaced by holes characteristic of emphysema. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. antibiotics. It is a common disease. air pollution. and each year about 30.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. COPD is distinguished pathologically by the destruction of lung tissue. indicate a poor prognosis. and by a tendency for excessive mucus production in the airway. Sources of noxious particles that can cause COPD include tobacco smoke. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. which 137 . which work against bacteria.
Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD.. 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. Active congestion of the lungs is caused by 138 . In COPD patients with low blood–oxygen levels. Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i. or cardiac insufficiencies (i. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion.. since they need to use it for 16 hours each day to derive benefit.e. high blood pressure. which leads to further difficulties in mobility. Specialized centres can offer treatments for patients with advanced disease. especially for patients with frequent exacerbations. Inhaled corticosteroids are commonly prescribed. This should be followed by a community/home maintenance program or by repeat courses every two years. oxygen is extremely flammable.7 The Respiratory System 7 can be accomplished in most cases by cessation of smoking. inability of the heart to function adequately). lung transplantation and lung-volume reduction). the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. A six. including noninvasive ventilation and surgical options (i.to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy.. bronchodilators).e.e. In addition. Some COPD patients do not find oxygen attractive.
caused by a cardiac disorder. Blood accumulates in the lower part of the lungs. Mitral stenosis.7 Diseases and Disorders of the Respiratory System 7 infective agents or irritating gases. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. and they begin to distend. and particles. rather than whole blood. The blood pressure becomes high in the alveolar capillaries. there is a bloody discharge. Eventually the pressure becomes too great. 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. and the skin takes on a bluish tint as the disease progresses. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. liquids. The affected person shows difficulty in breathing. causes chronic passive congestion. Inflammatory edema results from influenza or bacterial pneumonia. although there is usually enough unaffected lung tissue for respiration. when the remaining functioning tissue becomes infected. The major complication arises in mild cases of pneumonia. or to relaxation of the blood capillaries followed by blood seepage. Passive congestion is due either to high blood pressure in the capillaries. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue. narrowing of the valve between the upper and lower chambers in the left side of the heart. flooding them. In 139 . and blood escapes through the capillary wall into the alveoli. and the precipitating causes may somewhat differ. The alveolar walls and the capillaries in them become distended with blood. The walls of the alveoli also thicken and gas exchange is greatly impaired.
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 .
are not expanded with air. after reinflation of a collapsed lung. if too great a volume of intravenous fluids is given. The person’s skin turns blue. compressive. the person may actually drown in the lung secretions. their lungs show areas in which the alveoli. The term atelectasis can also be used to describe the collapse of a previously inflated lung. Excessive irradiation and severe allergic reactions may also produce this disorder. Acute cases can be fatal in 10 to 20 minutes. enlarged. and heavy. There are three major types of atelectasis: adhesive. wet. After an operation. This is typically caused by a failure to develop surface-active material 141 . and. The term is derived from the Greek words atele s and ektasis. either partially or fully. because of specific respiratory disorders. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed. These infants usually suffer from a disorder called respiratory distress syndrome. or air sacs. It may take only one or two hours for two to three quarts of liquid to accumulate. A person with pulmonary edema experiences difficulty in breathing. The lungs become pale. the blood pressure rises and edema ensues. with deep gurgling rattles in the throat. and obstructive. because he or she is too weak to clear the fluids. for unknown reasons. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. literally meaning “incomplete expansion” ¯ in reference to the lungs. 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. It can occur.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.
Dr. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242) 142 .7 The Respiratory System 7 X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis.
which manifests as a bluish tint to the skin.7 Diseases and Disorders of the Respiratory System 7 (surfactant) in the lungs. soot. The air passageways in the lungs normally secrete a mucous substance to trap dust. which frequently enter with inhaled air. After abdominal surgery. or elevation of the diaphragm. If a lung remains collapsed for a long period. It may also occur as a complication of abdominal surgery. Treatment for obstructive and compressive 143 . The symptoms in extreme atelectasis include low blood oxygen content. and bacterial cells. the respiratory tissue is replaced by fibrous scar tissue. Generally. Other causes of obstruction include tumours or infection. and the muscles beneath the lungs may be weakened. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. if these secretions become too abundant. Mucous plugs can result that cause atelectasis. an enlarged heart. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. they can be pushed out of the bronchi by coughing or strong exhalation of air. When a person undergoes surgery. displacement of the heart toward the affected side. absence of respiratory movement on the side involved. and consolidation of the lungs into a smaller mass. Local pressure can result from tumour growths. Collapse is complete if the force is uniform or is partial when the force is localized. and respiratory function cannot be restored. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements. Treatment for infants with this syndrome includes replacement therapy with surfactant. the anesthetic stimulates an increase in bronchial secretions. causing air trapped in the alveoli to be slowly absorbed by the blood.
or it may be lower. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. however. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. Lung Infarction Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. or air bubbles in the bloodstream (both of these are instances of embolism). 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). The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. 144 . such blockages fail to cause death of tissue because the blood finds its way by alternative routes. When pain is present it indicates pleural involvement. The section of dead tissue is called an infarct. shoulders. 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. infected. lung infarctions can follow blockage of a blood vessel. The pain may be localized around the rib cage. Ordinarily. If the lung is congested.7 The Respiratory System 7 atelectasis is directed toward removal of any obstruction or compressive forces. Pain is most severe on inhalation. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. and neck. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. when the lungs are healthy. infarcts that occur deep inside the lungs produce no pain. or inadequately supplied with air.
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. fever.. coughing. Cystic Fibrosis Cystic fibrosis.000 live births in these populations and is particularly concentrated in people of northwestern European descent. only persons inheriting a defective gene from both parents will manifest the disease). increased heartbeat. those individuals who have one normal copy and one defective copy of the particular gene involved).e. moderate difficulty in breathing. by the mid-1980s. The disorder was long known to be recessive (i. diminished breath sounds.. the chief symptom of which is the production of a thick. The dead tissue is replaced by scar tissue. and a dull sound heard when the chest is tapped. The disease has no manifestations in heterozygotes (i. also known as mucoviscidosis. when both 145 . is an inherited metabolic disorder. pleural rubbing. However. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. Infarcts that do not heal within two or three days generally take two to three weeks to heal. However. It is much less common among people of African ancestry (about 1 per 17. It is estimated to occur in 1 per 2.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood.000 live births) and is very rare in people of Asian ancestry.e. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures.
one out of four of their offspring will have the disease. they may expect that. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. called cystic fibrosis transmembrane conductance regulator. In 1989 the defective gene responsible for cystic fibrosis was isolated. Chronic cough. the mucus-secreting and sweat glands) in the respiratory and digestive systems. The thick. sticky mucus accumulates in the lungs. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet.g. foul-smelling stools are often the first signs of cystic fibrosis. recurrent pneumonia. 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. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. As a result. or CFTR. This results in chronic respiratory infections. plugging the bronchi and making breathing difficult. Within the cells of the lungs and gut. Bulky. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. greasy. The gene. In the digestive system. designated CFTR. the CFTR protein transports chloride across cell membranes and regulates other channels.7 The Respiratory System 7 parents are heterozygous. About 10 146 . chloride and sodium ions accumulate within cells. which is the most common cause of death of persons with cystic fibrosis. and the progressive loss of lung function are the major manifestations of lung disease. lies in the middle of chromosome 7 and encodes a protein of the same name. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. on the basis of chance.. often with Staphylococcus aureus or Pseudomonas aeruginosa.
protein. are given to thin mucus.” which is the definitive diagnostic test for the presence of cystic fibrosis. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. as well as in the identification of newborns who may be at risk for the disorder. making it easier for patients to breathe.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. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. sometimes in aerosolized form. and fat. lung transplantation may be considered. Mutations associated with cystic fibrosis can be detected in screening tests. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. in order to fight lung infections. a recombinant form of the enzyme deoxyribonuclease. The high salt content in perspiration is the basis for the “sweat test. which is powered by a compressor that sprays aerosolized drug into the airways. Many patients with cystic fibrosis regularly take antibiotics. who may pass a mutation on to their offspring. In severe cases. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. In addition. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. 147 . facilitating its clearance from the lungs through coughing. In addition. Medications such as dornase alfa. These tests are effective in the identification of adult carriers (heterozygotes). These agents may be administered by means of an inhaler or a nebulizer.
which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. which subsequently incorporated the normal genes into their DNA. has proved particularly effective in laboratory studies using human lung tissue. and adenovirus associated virus. The latter. Gene therapy first emerged as a potential form of treatment in 1990. the patients experienced severe side effects. gene therapy for cystic fibrosis has undergone significant refinement. As a result. 148 . However. the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. This first trial initially appeared to be successful. Since the 1990s.7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene. However. Delivery systems under investigation include cationic polymer vectors. since increased expression of the CFTR protein was observed shortly after treatment. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. These vectors were then transfected into the cultured cells. The same technology was used to insert the CFTR gene into a replication-deficient adenovirus that was then administered into the noses and lungs of patients. including lung inflammation and signs of viral infection. and the outcomes of clinical trials are marked by steady improvement. cationic liposomes. 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.
some people live 10 years or longer. called rales or “Velcro crackles. in different organs. The average duration of survival from diagnosis is four to six years. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. there is no effective treatment. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. Some individuals may benefit from single or double lung transplantation. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs. however.” are heard through a stethoscope applied to the back in the area of the lungs. or granulomas. Sharp crackling sounds. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. Aside from administration of supplemental oxygen. Other common changes are enlargement of the lymph 149 . the lung is commonly involved. with insidious onset of shortness of breath on exertion. pulmonary function testing shows a reduction in lung volume. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. A dry cough is common as well. In addition. The disease most commonly manifests between ages 50 and 70. Some individuals have clubbed fingertips and toes. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls.7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis.
When too much surfactant is released from the alveolar cells. The kidney is not commonly involved. or when the lung fails to remove the 150 . Occasionally. skin changes. minute structures in the lungs in which the exchange of respiratory gases occurs. The gas molecules must pass through a cellular wall. Eosinophilic granuloma is a lung condition that may spontaneously “burn out.7 The Respiratory System 7 glands at the root of the lung. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. Pulmonary Alveolar Proteinosis Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. Eosinophilic granuloma. It causes lesions in lung tissue and sometimes also in bone tissue. but in a small proportion of cases it progresses. inflammation in the eye. leading to signs of involvement in the affected area. and liver dysfunction. but often there is little interference with lung function. the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. Although its cause is unknown.” leaving the lung with some permanent cystic changes. Evidence of granulomas in the lung may be visible. a subgroup of immune cells. nerve sheaths are inflamed. a complex mixture of protein and lipid (fat) molecules. The disease usually remits without treatment within a year or so. the incidence is greatly increased in cigarette smokers. also known as histiocytosis X. leading finally to lung fibrosis and respiratory failure. In most cases the disease is first detected on chest radiographs. but some changes in blood calcium levels occur in a small percentage of cases. The alveoli are air sacs. is a disease associated with the excess production of histiocytes.
Wegener granulomatosis. X-rays most frequently show evidence of excess fluids in the lungs. Immunologic Conditions of the Lung The lung is often affected by generalized diseases of the blood vessels.7 Diseases and Disorders of the Respiratory System 7 surfactant. is an important cause of pulmonary blood vessel inflammation. it is sometimes fatal. One lung at a time is rinsed with a saltwater solution introduced through the windpipe. The fluids drawn back out of the lungs have been found to have a high content of fat. but subsequent treatments are often necessary. but its cause is not fully understood. Persons affected are usually between ages 20 and 50. The precipitating cause of the disease is unknown. Treatment involves removal of the material by a rinsing out of the lungs (lavage). Sometimes the lesions totally clear up after one procedure. but rarely so. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. The condition has been successfully treated by exchange blood transfusion. The skin becomes tinged with blue in the most serious cases. Pulmonary hemorrhage also occurs as part of a condition 151 . and it is often accompanied by chest pain and a dry cough. The disease can exist without causing symptoms for considerable periods. and spontaneous improvement has been known to occur. if treated. There may also be general fatigue and weight loss. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. an acute inflammatory disease of the blood vessels believed to be of immunologic origin.
however. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. it has surpassed breast cancer. following breast cancer. lung cancer is the second leading cause of death from cancer globally. In the United States. In the 21st century. which is also believed to have an immunologic basis.3 million deaths each year. by the use of pulmonary function tests. a slowly obliterative disease of small airways (bronchiolitis) occurs. leading finally to respiratory failure. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. Lung cancer was first described by doctors in the mid-19th century. These conditions have only recently been recognized and differentiated. accurate diagnosis has been much improved by refinements in radiological methods. Lung Cancer Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs. 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 emerged as the leading cause of cancer deaths worldwide. Pleural effusions may occur. In women. More rarely. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. The rapid increase in the worldwide prevalence of lung cancer was attributed mostly to the increased use of cigarettes following World War I. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was.7 The Respiratory System 7 known as pulmonary hemosiderosis. In the early 20th century it was considered relatively rare. and the lung parenchyma may be involved. resulting in an estimated 1. 152 .
Heavy smokers have a greater likelihood of developing the disease than do light smokers.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. visible lumps. chromium and nickel refiners. small-cell 153 . the tumour’s type and degree of invasiveness are determined. chest pain. secondhand smoke accounts for an estimated 3. and susceptibility to lower respiratory infections. jaundice. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. unexplained weight loss. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. In countries with a prolonged history of cigarette smoking. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body.400 deaths from lung cancer in nonsmoking adults in the United States each year. Uranium and pitchblende miners. In cases where the cancer has spread beyond the lungs. Of the two basic forms. Types of Lung Cancer Once diagnosed. The risk is also greater for those who started smoking at a young age. such as coal processors. a persistent cough or wheeze. Other risk factors include exposure to radon gas and asbestos. welders. between 80 and 90 percent of all cases are caused by smoking. Tumours can begin anywhere in the lung. The most common symptoms include shortness of breath. According to the American Cancer Society. or bone pain may occur. and roofers. tar refiners. bloody sputum. as do some workers in hydrocarbon-related processing. Lung cancer is rarely caused directly by inherited mutations. and workers exposed to halogenated ethers also have an increased incidence.
Diagnosis. Small-cell carcinoma (SCLC). About 10 percent of all lung cancers are large-cell carcinomas. This tumour is characterized by flat. Because it tends to spread quickly before symptoms become apparent. also called epidermoid carcinomas. Treatment. adenocarcinoma. Tumours often originate in the smaller. scalelike cells. Cancer cells may be detected in sputum. the survival rate is very low. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. There is some dispute as to whether these constitute a distinct type of cancer or are merely a group of unusual squamous cell carcinomas and adenocarcinomas. also called oat-cell carcinoma. 154 . but it is the most common type of lung cancer in the United States. is rarely found in people who have never smoked.or column-shaped. peripheral bronchi. SCLC is the most aggressive type of lung cancer. and they form structures that resemble glands and are sometimes hollow. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. Cells of adenocarcinoma are cube. pleura.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. and both lungs or metastasis to other organs. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. and large-cell carcinoma. or shaped like oat grains. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. It is characterized by cells that are small and round. oval. and Prevention Lung cancers are often discovered during examinations for other conditions. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. and it often develops in the larger bronchi of the central portion of the lungs.
Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . Even when it is detected early. lung cancer has a poorer prognosis than many other cancers. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. or the entire lung (pneumonectomy).7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. chemotherapy. For example. The choice of treatment depends on the patient’s general health. the stage or extent of the disease. The type of treatment an individual patient receives may also be based on the results of genetic screening. Surgery involves the removal of a cancerous segment (segmentectomy). which can identify mutations that render some lung cancers susceptible to specific drugs. and the type of cancer. As with most cancers. Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. Lung surgery is serious and can lead to complications such as pneumonia or bleeding. computed tomography (CT) scans. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. positron emission tomography (PET) scans. 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. and radiation. and magnetic resonance imaging (MRI). the five-year survival rate is about 50 percent. For this reason. treatments for lung cancer include surgery. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. a lobe of the lung (lobectomy). Noninvasive methods include X-rays.
Smokers who quit also reduce their risk significantly. Testing for radon gas and avoiding exposure to coal products. Enlargement of lymph glands in this region is common.7 The Respiratory System 7 following surgery to destroy small amounts of cancerous tissue. and other airborne carcinogens also lowers risk. diarrhea. which relies on heat derived from microwave energy to kill cancer cells. asbestos. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. Chemotherapy uses chemicals to destroy cancerous cells. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the 156 . Side effects include vomiting. particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. The probability of developing lung cancer can be greatly reduced by avoiding smoking. together with the many important structures situated within it. diseases of the MediastinuM and diaphragM The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. causing side effects that are similar to radiation therapy. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. or additional damage to the lungs. fatigue. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). noninvasive cysts of different kinds are also found in the mediastinum. but these chemicals also attack normal cells to varying degrees.
there is no difficulty. making breathing difficult. the extra gas pressure is relieved by exhaling. and the lungs begin to expand because the air inside has less pressure to contain it. which do not permit sufficient release of air. or scar tissue. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. 157 . Air trapped in the mediastinum expands as the diver continues to rise. If the diver holds his or her breath. When the alveoli of the lungs rupture because of traumatic injury or lung disease. and the trachea. major blood vessels. One pathway that the air can follow is through the lung tissue into the mediastinum. when he or she begins to ascend again. causing an air embolism. This area contains the heart. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. The air the diver breathes is more dense and concentrated than the air breathed on the surface. While the diver remains deeply submerged.7 Diseases and Disorders of the Respiratory System 7 heart and central blood vessels. or they can travel through the lung tissue to other areas of the body. rises too rapidly. the external pressure decreases. the external pressure upon his or her body increases. mucus plugs. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. and collapse blood vessels vital to circulation. however. main bronchi. The pressure may cause intense pain beneath the rib cage and in the shoulders. If the diver breathes normally or exhales as he or she ascends at a moderate rate. This usually occurs as a result of lung rupture. As a diver descends. the expanding air may compress the respiratory passageways. Air bubbles can then enter the veins and capillaries of the circulatory system directly. the lungs become overinflated and rupture. the released air seeks an area of escape. or has respiratory obstructions such as cysts.
and cyanosis (blue colouring of the skin). In many cases the cause of the paralysis cannot be determined. bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. In cases in which the symptoms are not severe. 158 . shock. For example. The function of the diaphragm may be compromised when the lung is highly overinflated. 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. Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. as occurs in emphysema. although some shortness of breath on exertion is often present. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. If there is respiratory or circulatory distress. respiratory failure. the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. this can lead to herniation of the abdominal viscera through the diaphragm.7 The Respiratory System 7 The symptoms of mediastinal emphysema may range from pain under the breastbone. and shallow breathing to unconsciousness. the air will be absorbed by the body. especially when the subject is recumbent (lying down). In some persons the diaphragm may be incompletely formed at birth.
In some cases of occupational exposure. however. many of which are acute in nature. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. affected persons are highly sensitive to substances such as dust or pollen. exposure to harmful irritants. hence. 159 . and drowning are other examples of acute conditions that can result in respiratory failure. such as asbestos and coal dust. Carbon monoxide poisoning. and. For most affected persons. Respiratory function can be severely compromised by a variety of other conditions. A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. leading to cancer and substantial loss of lung function. In the case of allergies. the lungs are exposed to the outside environment. reducing exposure to the irritant relieves the symptoms of their condition. decompression sickness. severe respiratory disease may ensue. such as respiratory distress syndrome. In occupational disease. causes respiratory disease in otherwise healthy workers.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. For example. altitude sickness. traumatic conditions. First.
which may be involved in any general inflammatory response. nasal polyps. or sinusitis. aspirin. dust mites. Although an initial episode can occur at any age. Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. however. In addition. asthma may develop in response to allergens. In adults. and breathlessness that range in severity from mild to life-threatening. it is often associated with an inherited susceptibility to allergens— substances. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. such as pollen. coughing. Adult asthma is sometimes linked to exposure to certain materials in the workplace. and grains. and exercise may cause it as well.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. weather conditions. second. the lung contains a very large vascular bed. and. In 160 . wood dusts. that may induce an allergic reaction. boys being affected more often than girls. such as chemicals. approximately half of all cases occur in persons younger than age 10. 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. but viral infections. Adults who develop asthma may also have chronic rhinitis. or animal dander. women are affected more often than men. Among adults. chest tightness. These substances provoke both allergic and nonallergic forms of the disease. stress may exacerbate symptoms. When asthma develops in childhood. Asthmatic episodes may begin suddenly or may take days to develop. third. The most common and most important of these is asthma. causing episodes of wheezing.
Although the mechanisms underlying an asthmatic episode are not fully understood. During an asthma attack. symptoms will subside if the causative agent is removed from the workplace. which results in tightening of the airways. narrower passages (bronchioles) and finally into the tiny. Encyclopædia Britannica. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. which can be divided into four categories: mild intermittent. Consequently.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. mild persistent. terminal bronchial tubes. and severe persistent. moderate persistent. 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. Asthma is classified based on the degree of symptom severity. most of these cases. Inc. air is obstructed from circulating freely in the lungs and cannot be expired. in general 161 . smooth muscles that surround the airways spasm.
cromolyn sodium and nedocromil. These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi. The obstruction of airflow may resolve spontaneously or with treatment. or systemic corticosteroids. A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. which are anti-inflammatory medications often prescribed for children. are in clinical trials.7 The Respiratory System 7 it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system. These 162 .. which are involved in mediating airway constriction and inflammation. which interrupt the chemical signaling within the body that leads to constriction and inflammation. swelling and inflammation of the bronchial tubes. Asthma medications are categorized into three main types: anti-inflammatory agents.e. and excessive secretion of mucus into the airways. bronchodilators. or they may be used to provide rapid relief from constriction of airways (quick-relief medications). which are the most potent and effective anti-inflammatory medications available. air is inspired but cannot be expired). These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). which relax smooth muscle constriction and open the airways. such as shortacting beta2-agonists and ipratropium bromide. long-acting beta2-agonists and methylxanthines (e..g. and leukotriene modifiers. The inflamed. which are leukotriene modifiers. theophylline). Long-term control medications include corticosteroids. and zileuton and zafirlukast. which suppress inflammation. which are bronchodilators. Agents that block enzymes called phosphodiesterases. mucus-clogged airways act as a one-way valve (i. Quick-relief medications may include bronchodilators.
too few to cause hookworm disease. In developed countries and especially in urban areas. and even cockroaches have been blamed for the increase. A prolonged asthma attack that does not respond to medication is called status asthmaticus.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. smoking. the number of asthma cases has increased steadily. Further investigation of this “helminthic therapy” in larger sample populations is under way. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. In addition to managing asthma with medications. crowded living conditions. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. However. 163 . are not entirely clear. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma. The ability to recognize the early warning signs of an impending episode is important. millions of people are infected with Necator americanus. In those areas. Air pollution. in many underdeveloped tropical regions of the world. very few people are affected by allergies or asthma. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. can relieve symptoms of allergy and asthma. Reasons for this dramatic surge in asthma cases. particularly among children. which may cause cardiovascular damage. Today asthma affects more than 7 percent of children and about 9 percent of adults. a species of hookworm. exposure to secondhand smoke. A person with this condition must be hospitalized to receive oxygen and other treatment.
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. studies have indicated that only one vaccine. nasal congestion. In allergic persons contact with pollen releases histamine from the tissues. which irritates the small blood vessels and mucus-secreting glands.7 The Respiratory System 7 There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. Antibiotics may also interfere with immune development. and tearing and itching of the eyes caused by allergy to the pollen of certain plants. 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. In a reverse scenario. such as ragweed in North America and timothy grass in Great Britain. also known as allergic rhinitis. chiefly those depending upon the wind for cross-fertilization. pertussis vaccine. 164 . may give rise to asthma. Seasonally recurrent bouts of sneezing. like other allergic diseases. The most effective long-term treatment is immunotherapy. Although not yet successfully confirmed. 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). shows a familial tendency and may be associated with other allergic disorders. such as dermatitis or asthma. Hay Fever Hay fever. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. is a common seasonal condition caused by allergy to grasses and pollens. Hay fever.
Broman—Root Resources 165 . 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. Louise K.
after 166 . granulomas. with shortness of breath persisting after the radiographic changes have disappeared. in the west of England. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). budgerigars (parakeets). A similar group of diseases occurs in those with close contact with birds. In more chronic forms of the condition. may be found in the lung.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. with inflammation of the smaller bronchioles. alveolar wall edema. If untreated. This causes an acute febrile illness with a characteristically fine opacification (clouding. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). the condition may become chronic. and there may be measurable interference with diffusion of gases across the alveolar wall. on the eastern seaboard of Canada. Farmer’s lung is common in Wisconsin. particularly proteins contained in the excreta of pigeons. One of these illnesses is the so-called farmer’s lung. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. and canaries. Airflow obstruction in small airways is present. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. or aggregations of giant cells. these represent different kinds of allergic responses to proteins from birds. and in France. or becoming opaque) in the basal regions of the lung on the chest radiograph. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. Variously known as pigeon breeder’s lung or bird fancier’s lung.
It is occasionally attributable to Aspergillus.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. 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. Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 . or in response to a variety of other agents. but sometimes the precise agent cannot be identified. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented.
chromate. beryllium. Asbestos. and aluminum dusts can cause a more severe pneumoconiosis. shortness of breath. the early symptoms of mild pneumoconioses include chest tightness. As little as 5 or 6 grams (about 0. is the most common cause of severe pneumoconiosis. The type and severity of disease depends on the composition of the dust. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. If enough scar tissue forms. small quantities of some substances. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. or air sacs. progressing to more serious breathing impairment. while milder irritants produce symptoms of lung disease only with massive exposure. The total dust load in the lung.2 ounce) in the lung can produce disease. Among inorganic dusts. and emphysema in the most severe cases. notably silica and asbestos. and cough. Typically. and coal dusts are other inorganic substances known to produce pneumoconiosis. silica. tin. Inhaled dust collects in the alveoli.7 The Respiratory System 7 irritants. often after relatively brief 168 . although silica exposure is also involved in many cases. iron. and infections of the already damaged lung can accelerate the disease process. and the clinical symptoms of pneumoconiosis are manifested. encountered in numerous occupations. chronic bronchitis. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. of the lung. the toxic effects of certain types of dust. clay. Graphite. lung function is seriously impaired. usually over a prolonged period of time. barium. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. produce grave reactions.
Silicosis is one of the oldest industrial diseases. nitrogen dioxide. acid. Histamines cause the air passages to constrict. Silicosis Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. sandblasting. and it remains one of the most common dust-induced respiratory diseases in the developed world. polishing. caused by fibres of cotton. tunnelers. or hemp that. Asbestosis has also been associated with cancers of the lung and other organs. mushrooms. and workers whose jobs involve grinding. stonecutters. stimulate histamine release. malt. The chemicals themselves may scar the delicate lung tissues. and chloride. quarry workers. even in previously nonallergic persons. which are quickly absorbed by the lining of the lungs. having been recognized in knife grinders and potters in the 18th century. and their irritant effect may cause large amounts of fluid to accumulate in the lungs. flax. (Silica is the chief mineral constituent of sand and of many kinds of rock. Prolonged exposure to organic dusts such as spores of molds from hay. Chemical irritants that have been implicated in lung disease include sulfur dioxide. In most instances. the patient may recover completely or may suffer from chronic bronchitis or asthma.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 exposure to massive amounts of dust. ammonia. when inhaled. Brown lung disease in textile workers is also a form of pneumoconiosis. The 169 . impeding exhalation. and buffing. and barley can produce lung disease through a severe allergic response within a few hours of exposure.) The disease occurs most commonly in miners. Once exposure to the chemical ceases. sugarcane. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop.
called macrophages. however. and pneumonia. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses. emphysema.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. There is no cure for silicosis. Silica particles. In the actual disease process. cannot be digested by the macrophages and instead kill them. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. that serve to protect the body from bacterial invasion. In the past a large proportion of sufferers of silicosis died of tuberculosis. is a respiratory disorder caused by repeated inhalation of 170 . control of the disease lies mainly in prevention. and the abdominal lymph nodes.000. Only very small silica particles less than 10 microns (0. though this has changed with the availability of drug therapies for that disease. The symptoms of silicosis are shortness of breath that is followed by coughing. and weakness. and gas exchange is poor.000 particles of silica per cubic foot (about 210. difficulty in breathing.000 per litre) of air. and particles of one to three microns do the most damage. also known as coal-worker’s pneumoconiosis. These whorls of fibrous tissue may spread to involve the area around the heart. 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. the openings to the lungs.0004 inch) in diameter penetrate to the finer air passages of the lungs. Silicosis predisposes a person to tuberculosis. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. Lung volume is reduced. Black Lung Black lung. since there is no effective treatment. and.
Georgius Agricola. and as a fire protectant sprayed inside buildings.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 coal dust over a period of years. ceiling tiles. tuberculosis is also more common in victims of black lung. and later in flooring. and the extent of disease is clearly related to the total dust exposure. brake linings. It is not clear. There is strong evidence that tobacco smoking aggravates the condition. The early stages of the disease (when it is called anthracosis) usually have no symptoms. but it also occurs in soft-coal miners and graphite workers. as coal dust often is contaminated with silica. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. a German mineralogist. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to 171 . Onset of the disease is gradual. 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 it is now widely recognized. first described lung disease in coal miners in the 16th century. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. whether coal itself is solely responsible for the disease. It may be the best known occupational illness in the United States. The disease is most commonly found among miners of hard coal. The first disease recognized to be caused by asbestos was asbestosis. which causes similar symptoms. led to a virtual epidemic of asbestos-related disease 20 years later. however.
A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. but survival after diagnosis is less than two years.7 The Respiratory System 7 thickening of the pleura. Asbestos has been suspected to play a role in stimulating certain cellular events. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people. 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. especially when associated with cigarette smoking. there was a major increase in the risk for lung cancer. is inhaled than if chrysotile is inhaled. all the respiratory changes associated with asbestos exposure are irreversible. Not all types of asbestos are equally dangerous. and. But exposure to any type of asbestos is believed to increase the risk of lung cancer. inhalation of asbestos remains a significant risk for the workers removing the material. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. It is not yet understood exactly why asbestos devastates the tissues of the lungs. In most cases. a blue asbestos that comes from South Africa. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer. Malignant mesothelioma is rare and unrelated to cigarette smoking. As far as is known. when both cigarette smoking and asbestos exposure occurred. The risk of mesothelioma in particular appears to be much higher if crocidolite. All 172 . thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour.
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industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.
Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing
The Respiratory System
beryllium alloys, and a slow-developing chronic disease occurring in scientific and industrial workers who are exposed to beryllium-containing fumes and dust. The acute disease involves both skin and lungs, causing a burning rash, eye irritation, nasal discharge, a cough, and chest tightness. The skin disease is caused by direct contact with beryllium salts and the lung disease by inhalation of metal dust or beryllium compounds. Most of those affected by acute berylliosis recover within a few months, but a small number of patients develop a highly fatal inflammation of the lung within 72 hours after a brief, massive exposure to beryllium. The chronic disease may occur more than 15 years after exposure, although the later it develops, the milder it is likely to be. It generally causes shortness of breath, especially after exercise, exhaustion, and a dry cough and can produce a permanent, though moderate, disability.
Byssinosis, or brown lung, is a respiratory disorder caused by inhalation of an endotoxin produced by bacteria in the fibres of cotton, flax, hemp, and other textiles. Byssinosis is common among textile workers, who often inhale significant amounts of cotton dust. Cotton dust may stimulate inflammation that damages the normal structure of the lung and causes the release of histamine, which constricts the air passages. As a result, breathing becomes difficult. Over time the dust accumulates in the lung, producing a typical discoloration that gives the disease its common name. Byssinosis was first recognized in the 17th century and was widely known in Europe and England by the early 19th century. Today it is seen in most cotton-producing
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
regions of the world. Several years of exposure to cotton dust are needed before byssinosis develops, and workers with lower grade disease usually recover completely upon leaving the industry or moving into an area with less dust. Persons with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure continues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Because cotton is by far the most common cause of byssinosis, this form of the condition has been variably known as cotton-dust asthma and cotton-mill fever.
Respiratory Toxicity of Industrial Chemicals
Toluene diisocyanate, used in the manufacture of polyurethane foam, may cause occupational asthma in susceptible individuals at very low concentrations. In higher concentrations, such as may occur with accidental spillage, it causes a transient flulike illness associated with airflow obstruction. Prompt recognition of this syndrome has led to modifications in the industrial process involved. Although the acute effects of exposure to many of these gases and vapours are well documented, there is less certainty about the long-term effects of repeated low-level exposures over a long period of time. This is particularly the case when the question of whether work in a generally dusty environment has contributed to the development of chronic bronchitis or later emphysema. In other words, whether such nonspecific exposures increase the risk of these diseases in cigarette smokers. Many chemicals can damage the lung in high concentration: these include oxides of nitrogen, ammonia,
The Respiratory System
chlorine, oxides of sulfur, ozone, gasoline vapour, and benzene. In industrial accidents, such as occurred in 1985 in Bhopal, India, and in 1976 in Seveso, near Milan, people in the neighbourhood of chemical plants were acutely exposed to lethal concentrations of these or other chemicals. The custom of transporting dangerous chemicals by rail or road has led to the occasional exposure of bystanders to toxic concentrations of gases and fumes. Although in many cases recovery may be complete, it seems clear that long-term damage may occur.
Disability and Attribution of Occupational Lung Diseases
Occupational lung diseases are of social and legal importance. In such cases, respiratory specialists must assess the extent of an individual’s disability and then form an opinion on whether an individual’s disability can be attributed to an occupational hazard. Pulmonary function testing and tests of exercise capability provide a good indication of the impact of a disease on the physical ability of a patient. However, it is much more difficult to decide how much of a patient’s disability is attributable to occupational exposure. If the exposure is historically known to cause a specific lesion in a significant percentage of exposed persons, such as mesothelioma in workers exposed to asbestos, attribution may be fairly straightforward. In many cases, however, the exposure may cause only generalized pulmonary changes or lung lesions for which the precise cause cannot be determined. These instances may be complicated by a history of cigarette smoking. Physicians asked to present opinions on attributability before a legal body frequently must rely on the application of probability statistics to the individual case, a not wholly satisfactory procedure.
Over time. to an increased respiratory rate. conditions arising from exposure to extremes in atmospheric pressure. a clot is replaced with 177 . When severe. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. which occurs during mountain climbing and diving.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. and metabolic disorders. In addition. when the infarction is massive. comprise a diverse group of diseases and disorders. these changes are known as a pulmonary infarction. Circulatory Disorders The lung is commonly involved in disorders of the circulation. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. environmental pollutants. 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. The causative factors of these conditions may include accidents. Early mobilization after surgery or childbirth is considered an important preventive measure. which has usually formed in the veins of the legs or of the pelvis. ranging from poor pulmonary circulation to carbon monoxide poisoning. This occurs most often during a postoperative period when the affected individual is immobilized in bed. toxic gases. in which the pressure in the main pulmonary artery is persistently increased. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. The consequences of embolism range from sudden death. slight fever.
The obstructing lesions can be surgically removed in some instances. and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. ultimately. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. with consequent shortness of breath. usually as a consequence of coronary arterial disease. long-term evaluation and treatment. When the 178 . a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. follows left ventricular failure. thereby relieving symptoms of breathlessness. In primary pulmonary hypertension. In some cases. a condition of unknown origin. right ventricular heart failure. lung transplantation is necessary. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. In addition to chest X-rays and basic pulmonary function tests. Prostacyclin can sometimes be given in oral or inhaled forms. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. affected individuals require careful. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. causing shortness of breath on exertion and.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. While some medications such as calcium channel blockers may be taken orally. usually after increasing disability with severe shortness of breath.
5 pounds). a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. This complication is especially common in premature newborns. respiratory distress syndrome of infants was frequently fatal. Although respiratory distress syndrome occurs mostly in premature. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. and abnormally low levels of oxygen in the arterial blood.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). It is characterized by extremely laboured breathing. low-birth-weight infants (those weighing less than 2. which does the work of the lungs by oxygenating the 179 .5 kg. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. The disorder arises because of a lack of surfactant. These changes contribute to the shortness of breath and account for the blood staining of the sputum. or approximately 5. particularly those born to diabetic mothers. The syndrome was formerly the leading cause of death in premature infants. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. In infants it is also called hyaline membrane disease. cyanosis (a bluish tinge to the skin or mucous membranes). it also sometimes develops in full-term infants. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. Before the advent of effective treatment. 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.
Many. although superimposed infection or multiple organ failure can result in death. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. but not all. This episode spurred renewed attention to this problem. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. Many causes of respiratory distress syndrome of adults have been identified. Life-support treatment with assisted ventilation rescues many patients.000 people during that week and the subsequent three weeks. Most children who survive have no aftereffects. This syndrome is known as acute respiratory distress syndrome of adults. Acute respiratory distress syndrome carries about a 50 percent mortality rate. which had been intermittently considered since the 14th century 180 . bacterial or viral pneumonia. Recovery and repair of the lung may take months after clinical recovery from the acute event. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. 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. exposure of the lung to gases. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. 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. aspiration of material into the lung (including water in near-drowning episodes). of the victims already had chronic heart or lung disease. widespread bilateral lung injury. In adults.7 The Respiratory System 7 blood and removing carbon dioxide.
Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories. leads to the formation of photochemical smog. and finally the passage of legislation banning open coal burning. This form of pollution. together with the bright sunlight and frequently stagnant air. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. respiratory tract infections in the young and old. and possibly lung cancer. Photos. 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. is associated with excess mortality and increased prevalences of chronic bronchitis.com/Jupiterimages 181 . The large number of automobiles in that city. common in many cities using coal as heating fuel. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles. the factor most responsible for the pollution.
Eye irritation. including Mexico City. Bangkok. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children.7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. The indoor environment can be important in the genesis of respiratory disease. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. and the impact of these exposures is an area of intense scientific investigation. chest irritation with cough. and São Paulo. These levels are commonly exceeded in many places. followed by the formation of nitrogen dioxide by oxygenation. In developing countries. which begins as emissions of nitrogen oxides. Ozone is the most irritant gas known. through a complex series of reactions in the presence of hydrocarbons and sunlight. Such exposures are common in the lives of millions of people. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. 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.12 part per million. and repeated exposures may lead to lung cancer. and possibly the exacerbation of asthma occur as a result. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. In developed countries. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. and finally. 182 .
When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. as part of his detailed analysis of atmospheres in underground mines. a condition in which hemoglobin is deficient. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. the subject feels dizzy and is unable to perform simple tasks. 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. For this reason. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. 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. including combustion of gas in automobile engines. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. Carbon monoxide is produced by incomplete combustion. leaving only 60 percent available to bind to oxygen). 183 . and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. Judgment is also impaired. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity.
Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. or bicarbonate gain. There are two primary types of acidosis: respiratory and metabolic. Causes of metabolic acidosis include uncontrolled diabetes mellitus. among others. shock. including the blood. congestive heart failure. pulmonary embolism. or pneumonia. Alkalosis may be either metabolic or respiratory in origin. in the body fluids. such as general anesthetic agents. which may be caused by anxiety. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. or low level of alkalinity. including the blood. This may be caused by severe acute or chronic lung disease. Respiratory alkalosis results from hyperventilation. in the body fluids. Hyperventilation is defined as a sustained abnormal increase in breathing.7 The Respiratory System 7 Acidosis Acidosis is an abnormally high level of acidity. asthma. During hyperventilation the rate of 184 . or by certain medications that suppress respiration in excessive doses. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. certain drugs or poisons. Metabolic alkalosis results from either acid loss. and renal failure. 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. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). such as pneumonia or emphysema. Alkalosis and Hyperventilation Alkalosis is an abnormally low level of acidity. or high level of alkalinity.
such as respiratory acidosis or hyperventilation.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. 185 . Imbalances in the exchange of these gases can lead to dangerous respiratory disorders. Encyclopædia Britannica. causing symptoms such as shortness of breath. In addition. Inc. accumulation of fluid in the alveolar spaces can interfere with gas exchange.
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
Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). When a pilot ascends to a higher altitude. such as the ears. 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. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. however. In certain cavities of the body. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. underwater divers. and torso. small amounts of the gases that are present in the air.7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. A fatal form of barotrauma can occur in submariners and divers. At atmospheric pressure the body tissues contain. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). or under the skin of the neck. the external pressures upon his or her body decrease. and these dissolved gases come 190 . such as the eardrum. face. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. and intestines. Pilots of unpressurized aircraft. the pleural spaces. sudden expansion of air trapped within the thorax can burst one or both lungs. 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. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. lungs. there are air pockets that either expand or contract in response to changes in pressure. sinuses. in solution. For example. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung.
numbness. signals the onset of pulmonary decompression sickness. The gases then pass to the respiratory tract and are exhaled from the body. Bubbles forming in the brain. The nervous system is composed of about 60 percent lipids. Therefore. spinal cord. rapid respiration.” The major component of air that causes decompression maladies is nitrogen. 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. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s 191 . pain is usually severe and mobility is restricted. The term bends is derived from this affliction. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. as the affected person commonly is unable to straighten joints. If the ascent is slow enough. Conversely. Shallow. Nitrogen is much more soluble in fatty tissue than in other types. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). often associated with a sharp retrosternal pain on deep inspiration. the gases have time to diffuse from the tissues into the bloodstream.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 out of solution. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled. nausea. and personality changes. speech defects. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. When the pressure decreases. the “chokes. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). When bubbles accumulate in the joints. the excess nitrogen is released.
the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. a burning sensation while breathing. Other symptoms include chest pain. If one descends to a depth of about 30 metres (100 feet). 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). and the size of the lungs decreases. indicate nitrogen bubbles in the respiratory system. is a type of barotrauma involving compression of the lungs and thoracic cavity. It most commonly occurs during a breath-holding dive underwater. while too little air causes compression and collapse of the lung walls. known as the chokes. Because the lung tissue is elastic and interspersed with tubules and sacs of air. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. Too much air causes rupture of lung tissue. and the lung may collapse. Thoracic Squeeze Thoracic squeeze. Excessive coughing and difficulty in breathing. The outer linings of the lungs (pleural sacs) may separate from the chest wall. the lung shrinks to about one-fourth its size at the surface.7 The Respiratory System 7 itches. Usually these symptoms pass in 10 to 20 minutes. but this process is not always able to reverse damage to tissues. During the descent. the air inside the lungs is compressed. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. and severe shock. or lung squeeze. If compression continues. an increase in pressure causes air spaces and gas pockets within the body to compress. 192 . it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled.
the diver may have difficulty in breathing. Any symptoms of thoracic squeeze call for prompt medical attention. and gives up the remaining tidal air in his or her lungs. Drowning Drowning is suffocation by immersion in a liquid. loses consciousness. It is now known that victims immersed for an hour or longer may be totally salvageable. or breathing—at the time of rescue.300 feet).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. A fuller appreciation of the 193 . pulse. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. 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. 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. their lungs. more than 10 times the depth that humans can tolerate. usually water. having no measurable vital signs—heartbeat. physically and intellectually. and may even become unconscious. although they lack evidence of life. The sperm whale is reported to dive to about 1. but eventually it ceases. may exhale frothy blood. do not separate from the chest wall. even when reduced. If the thoracic squeeze has been sufficient to cause lung damage. Artificial respiration may be necessary if the breathing has stopped.000 metres (3. These aquatic mammals have been found to have more elastic chest cavities than humans. Deprived of oxygen the victim stops struggling. Until recently. and their bodies are adapted to use the gases in the bloodstream more conservatively. There the heart may continue to beat feebly for a brief interval.
despite a total absence of respiratory gas exchange. Scientists have determined that vestiges of the reflex persist in humans. In this suspended state. Often. so that many people who once would have been given up for dead are being saved. known as the mammalian diving reflex. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. thus permitting seagoing mammals to hunt for long periods underwater.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. actual aspiration of water into the lungs may or may not occur. and surface areas of the body to the heart and the brain. 194 . the volume of fluid entering the lungs rarely exceeds a glassful. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. When aspiration does occur. in other respects it performs normally.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. enhances survival during submersion. The mechanism is powerful in children. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. Up to 15 percent of drownings are “dry. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. It diverts blood from the limbs. quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. Even though the heart functions at a slower rate. A natural biological mechanism that is triggered by contact with extremely cold water. abdomen.
Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. 195 . Such warmwater drownings occur commonly in domestic bathtubs. survival following hypothermic coma is almost 75 percent. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues.” “Lifeless” immersion victims with core temperatures as low as 62. and promotes unconsciousness.6 °F (17 °C) have survived. None of these effects is imminently life-threatening. slows the heart rate. 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). so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain.
In addition. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. This expansion of scientific understanding has enabled important progress in respiratory medicine. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. and pathology of the human respiratory system is known as pulmonology. especially in the area of disease prevention. physiology. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. many technological advances. A cough productive of sputum is the most important manifestation of inflammatory or 196 . particularly concerning techniques employing X-ray imaging or endoscopy. Likewise. One of the most important advances in the history of respiratory medicine was the development of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. Today.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. have contributed to improvements in the diagnosis and evaluation of respiratory disease. or respiratory medicine.
or shortness of breath. or with the onset of a severe attack of asthma. 30 to 60 ml of sputum are produced in a 24-hour period. or walking uphill. Severe fibrosis of the lung. it is constantly present. The shortness of breath may vary in severity. Although it may result simply from an exacerbation of an existing infection. and tasks such as dressing cannot be performed without difficulty. and fluid may accumulate in 197 .7 Approaches to Respiratory Evaluation and Treatment 7 malignant diseases of the major airways. the lung capillaries become engorged. commonly. may also cause severe and unremitting dyspnea. It may become so severe as to immobilize the victim. What is noted is a slowly progressive difficulty in completing some task. of which bronchitis is a common example. in which there is irreversible lung damage. it may also indicate the presence of inflammation. capillary damage. resulting from occupational lung disease or arising from no identifiable antecedent condition. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. but in diseases such as emphysema. When this occurs. as when a foreign body is inhaled into the trachea. This sensation. if the right ventricle that pumps blood through the lungs is functioning normally. 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. of complex origin. such as walking up a flight of stairs. Hemoptysis is also a classic sign of tuberculosis of the lungs. or a tumour. More often. and. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. it is insidious in onset and slowly progressive. particularly in the first two hours after awakening in the morning. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. may arise acutely. playing golf.
The pain disappears when fluid accumulates in the pleural space. but absence of the symptom does not mean that serious lung disease is not present. Acute pleurisy with pain may signal a blockage in a pulmonary vessel. 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. Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. A wheeziness in the chest may be heard. a condition known as a pleural effusion. but it is most often associated with an attack of pneumonia. Severe. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process.7 The Respiratory System 7 small alveoli and airways. To these major symptoms of lung disease—coughing. Fortunately. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. and chest pain—may be added several others. of the toes) called “clubbing. rarely. which leads to acute congestion of the affected part. since. can cause pleurisy. pulmonary embolism. Some diseases of the lung are associated with the swelling of the fingertips (and. It is commonly dyspnea that first causes a patient to seek medical advice. a small lung cancer that is not obstructing an airway does not produce shortness of breath. pain of this severity is rare. such as a mesothelioma. diffuse 198 . For example. This is caused by narrowing of the airways.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). severe chest pain may be caused by the spread of malignant disease to involve the pleura. dyspnea. In addition. Chest pain may be an early symptom of lung disease. for example. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. such as occurs in asthma. or by a tumour that arises from the pleura itself.
physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints.7 Approaches to Respiratory Evaluation and Treatment 7 fibrosis of the lung from any cause. Thus. are variable and nonspecific. general psychological depression. especially in the early stage. a disinclination for physical activity. the first symptom may be a swelling of the lymph nodes that drain the affected area. a 199 . In some lung diseases. for example. or seemingly minor symptoms as the first indication of disease. since a peripheral neuropathy may also be the presenting evidence of these tumours. as it may reveal the presence of an area of inflammation. particularly the small nodes above the collarbone in the neck. The generally debilitating effect of many lung diseases is well recognized. and some symptoms apparently unrelated to the lung. this unusual sign may disappear after surgical removal of the tumour. In the case of lung cancer. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. the patient may feel as one does when convalescent after an attack of influenza. A person with active lung tuberculosis or with lung cancer. Not infrequently. unusual fatigue. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. as may sensory changes in the legs. Loss of appetite and loss of weight. may be diverse indicators of lung disease. Because the symptoms of lung disease. Methods of inVestigation Physical examination of the chest remains important. a hip fracture from bone metastases. may be conscious of only a general feeling of malaise. Not infrequently. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. cerebral signs from intracranial metastases. such as mild indigestion or headaches. and lung cancer.
and the perfusion scan allows visualization of the blood vessels in the lungs. in the case of ventilation scanning. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. or injected. in the case of perfusion scanning. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds. tender areas. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. In these techniques. sputum examination for malignant cells is occasionally helpful. the lung tissue. or the pleural space. The sounds detected with a stethoscope may reveal abnormalities of the airways. percussion to gauge the resonance of the underlying lung. Methods of examination include physical inspection and palpation for masses. While the resolution of computerized tomography is much better than most other visualization techniques. and abnormal breathing patterns. The ventilation scan allows visualization of gas exchange in the bronchi and trachea.7 The Respiratory System 7 pleural effusion. a radioactive tracer molecule is either inhaled. or an airway obstruction. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. 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. MRI is useful for imaging the heart and blood vessels within the 200 . because the technique is not well suited to imaging air-filled spaces.
and gas exchange are compared before. physicians can collect fluid and small tissue samples from the airways.7 Approaches to Respiratory Evaluation and Treatment 7 thorax. and after exercise. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. By feeding a surgical instrument through a special channel of the bronchoscope. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function. the stiffness of the lung. total ventilation. the distribution of ventilation within the lung. trachea. Ventilatory capability can be measured with a peak flow meter. 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. Spirometry. or the pressure required to inflate it. Tests of exercise capability. are useful in assessing functional impairment and disability. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. and major bronchi. which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). during. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. and the rate of gas transfer across the lung. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. 201 . which is often used in field studies. in which workload. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. airflow resistance.
or the transfer of gas between the alveoli and the blood.7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. Tests of ventilatory function include the following measurements: residual 202 . 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. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs).
expressed in litres of air per minute. vital capacity. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. of the lungs. and maximal expiratory flow rate (MEFR). which is measured by a dilution method. or capillaries. who discovered X-rays in 1895. maximum air volume expelled in a time interval. air remaining within the chest after a maximal expiration. functional residual capacity (FRC). Chest X-ray X-ray imaging is a valuable diagnostic technique used in medicine. taken to look for infections such as 203 . Except for the residual volume. maximal flow rate of a single expelled breath. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. or air within the chest at the end of a quiet expiration. maximal air volume expelled in 12 to 15 seconds of forced breathing. This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. forced expiratory volume (FEV). One of the most common screening roentgenograms is the chest film. all the other volumes may be recorded with a spirometer.7 Approaches to Respiratory Evaluation and Treatment 7 volume (RV). 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. which measure the capacity of the lungs to move air in and out. the resting lung volume. and total lung capacity (TLC). tidal volume. Ventilation tests. maximum air volume that can be expelled after a maximum inspiration. air volume within the chest in full inspiration. breathing movements may also be registered graphically on a spirogram. volume of a breath. include maximal voluntary ventilation (MVV).
the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 . the blockage of one of the pulmonary arteries or of a connecting vessel. but. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. For the perfusion part of the scan. thereby narrowing the passageway and hindering the flow of blood. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. To track the movement of air. unfortunately. 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. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. This approach may be taken for patients with advanced or rapidly spreading lung cancer. Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. A scanner that contains a radiation-sensitive camera is then used to collect images of the gamma rays emitted from the tracer as it circulates through the lungs. 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.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. or VQ (ventilation quotient) scan. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs.
a mismatch between the two scans is indicative of disease. or areas where the tracers become highly concentrated and therefore produce bright areas in the images.or blooddeprived. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent 205 . highlight places within the lungs where air or blood have accumulated abnormally. including angiography. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. In contrast. the tissues affected will be either oxygen. The appearance of hot spots. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. Bronchoscopy Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. and another set of images is taken with the scanner. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan.7 Approaches to Respiratory Evaluation and Treatment 7 with technetium). In both ventilation and perfusion scans. normal air and blood flow are reflected in the even distribution of tracers within the lungs. the levels of radioactivity are exceptionally low and pose a very small risk to patients. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism. Although the tracers used in lung ventilation/perfusion scanning are radioactive. In general. the ventilation and perfusion scans match for a person with healthy lungs. Thus. he or she may subsequently undergo more invasive procedures. Nutrient deprivation renders the tissue highly susceptible to death.
Encyclopædia Britannica.7 The Respiratory System 7 The trachea and major bronchi of the human lungs. 206 . Inc.
both flexible and rigid scopes have a channel through which instruments can be passed. because of their ability to bend and twist. known as a rigid bronchoscope. In addition.7 Approaches to Respiratory Evaluation and Treatment 7 cough or who are coughing up blood. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. consists of a metal tube that has a wide suction channel. Bronchoscopy is also employed to remove foreign objects from the airways. blood) to be removed during an examination. and to assist in the placement of stents (tubes. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. which enables large volumes of fluid (e.g. Flexible scopes. they remain superior for specific applications. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways.. 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. There are two types of bronchoscopes. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. to deliver certain therapeutic agents directly into the lungs. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. 207 . All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. 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. The second type of scope.
causing a condition known as pneumothorax. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs. Bleeding is especially common following biopsy. mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. bleeding subsides without the need for medical intervention. Mediastinoscopy Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. upon waking. which can cause side effects in some people.7 The Respiratory System 7 Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. which occurs when the instrument is not sanitized properly. For example. In addition. the movement of a bronchoscope through the airways often scratches superficial tissues. trachea. because of the discomfort caused by the device. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity. as well as a set of lymph nodes. serving as one of the primary 208 . In contrast. causing them to bleed. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. rigid bronchoscopy. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. necessitates the use of general anesthesia. esophagus. Because the region of the mediastinum contains the heart. there are several important risks associated with the bronchoscopy procedure itself. and thymus gland. including nausea and vomiting. In most cases. however.
A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. 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. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. flexible instrument—is then passed through the incision and into the space between the lungs. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). A mediastinoscope—a thin. This may also be performed for other tissues in the region that display signs of disease. 209 . During mediastinoscopy. such as abnormal growths or inflammation. Severe complications— such as bleeding. Staging involves the investigation of cells to assess the degree to which cancer has spread. Most patients recover within several days following mediastinoscopy. In cancer staging. particularly for cellular defects associated with cancer and for the presence of infectious organisms. a surgeon first makes a small incision in the patient’s neck. light-emitting. and the procedure is associated with a very low risk of complications. the doctor is able to investigate the surfaces of the various structures. including computerized axial tomography and positron emission tomography. immediately above the sternum. The biopsy samples are then investigated for evidence of abnormalities. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. By carefully maneuvering the scope in the space. This step of the procedure is known as mediastinotomy. infection. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques.
A mixture of helium and oxygen is used to treat some diseases of airway obstruction. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. each of which may be tailored to a specific disease. as in treatment of cystic fibrosis. In addition. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm.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. mucolytics. or a fog (as in an oxygen tent or a croup tent). There are different methods of treatment employed in respiratory therapy. Oxygen may be administered in controlled amounts to assist laboured breathing. and antibiotics. adjustment. respiratory therapists are experts in the setup. Medications. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. produces vibrations that help to loosen and mobilize secretions. One of the conditions frequently dealt with is obstruction of breathing passages. and maintenance of mechanical ventilators. 210 . Chest percussion. 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. 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. hot steam. such as bronchodilators. Therapy may involve the administration of gases for inhalation. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions.
Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. veins. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. and antibiotics. due to the emergence of resistant organisms. the arterioles.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. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. and larger arteries respond to some degree. When administered in nasal sprays or drops or in devices for inhalation. That is. decongestants and antihistamines are available over the counter. decongestants. The constricting action chiefly affects the smallest arteries. However. there are three groups. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. they mimic the effects of stimulation of the sympathetic 211 . thus reducing blood flow to the inflamed areas. antihistamines. that are of particular importance in the routine treatment of respiratory illness. In countries such as the United States. Decongestants are sympathomimetic agents. The relative safety and efficacy of these drugs has made them generally reliable medications. and thus they are used by many people.
however.7 The Respiratory System 7 division of the autonomic nervous system. inflammation. or heart palpitations. The oldest and most important decongestant is ephedrine. dizziness. which has been used in Chinese medicine for more than 5. results in absorption into the bloodstream. they must be used repeatedly. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. in which epinephrine constricts the blood vessels of the skin. They include phenylephrine hydrochloride. Ephedrine and other decongestants are made by chemical synthesis. amphetamine and several derivatives. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. thereby preventing histaminetriggered reactions under such conditions as stress. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . insomnia. any of several species of shrubs of the genus Ephedra. an alkaloid originally obtained from the leaves of ma huang. causing anxiety. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. following its release from certain large cells (mast cells) within the body. Because none of them has a sustained effect.000 years. too frequent use. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. headache. One of the chief drugs of the group is epinephrine. and allergy. and naphazoline hydrochloride.
blurred vision. among them hay fever and seasonal rhinitis. Nasal irritation and watery discharge are most readily relieved.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. compounds that were more potent. subsequently. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. More than 100 antihistaminic compounds soon became available for treating patients. tested later and found to be more potent. Antihistamines are readily absorbed from the alimentary tract. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. Used in sufficiently large doses. The most common side effect in adults is drowsiness. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. were too toxic for clinical use. headache. Antihistamines are not usually beneficial in treating the common cold and asthma. Anilinetype compounds. and most are rendered inactive by monoamine oxidase enzymes in the liver. and dryness of the mouth. it is unlikely that he or she will benefit from them. antihistamines can control certain allergic conditions. edema. itching. nearly all antihistamines produce undesirable side effects. Persons with urticaria. In 1942. and less toxic were prepared. The development of these antihistamines dates from about 1937. If a patient’s condition does not improve after three days of treatment with antihistamines. and certain sensitivity reactions respond well. more specific. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. The first antihistamines were derivatives of ethylamine. Other side effects include gastrointestinal irritation. 213 .
erythromycin. in which tissues such as the 214 . They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era. such as the tetracyclines. Macrolides. and for a sufficient length of time to ensure that the infection is totally eradicated.7 The Respiratory System 7 During the 1970s an H2-blocking agent. and they are especially important in the treatment of bacterial respiratory infections. but they can be given parenterally. cimetidine (Tagamet) was introduced. 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. which inhibit bacterial protein synthesis. the bacillus responsible for diphtheria. Oxygen therapy is used for acute conditions.g.. Some are highly specific. at a high enough concentration to be effective (but not cause side effects). Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. azithromycin) are particularly effective in the treatment of bacterial respiratory infections. These drugs are usually administered orally. act against a broad spectrum of different bacteria. Oxygen Therapy The medical administration of oxygen is an important means of treating respiratory disease. Antibiotics known as macrolides (e. clarithromycin. are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin. whereas others.
In emergency situations.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. 215 . Another form of therapy. home oxygen therapy may be prescribed by a physician. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). In addition. Some patients may require oxygen administration via a transtracheal catheter. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. 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. known as hyperbaric oxygen therapy (HBOT). portable compressed-gas oxygen cylinder. a device inserted into the nostrils that is connected by tubing to an oxygen system. however. These applications are controversial. 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. such as chronic obstructive pulmonary disease (COPD). For patients affected by chronic lung diseases. oxygen may be delivered through a face mask or through a nasal cannula. which is inserted directly into the trachea by way of a hole made surgically in the neck. 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. In both the hospital and the home settings. HBOT has been promoted as an alternative therapy for certain conditions.
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. Stationary and portable oxygen concentrators have been developed for use in the home. Another form of oxygen storage is in compressed-gas cylinders. Liquid oxygen can be stored in small or large insulated containers. as opposed to releasing gas constantly. oxygen. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood 216 . Oxygen concentrators. a measure known as the flow rate. which necessitates more-frequent cylinder replacement. provide a method of storing oxygen at concentrations greater than that occurring in ambient air. it is converted to a gas. In the ABG test.7 The Respiratory System 7 There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. Oxygen also can be stored as a highly concentrated liquid. which draw in surrounding air and filter out nitrogen. Flow rate is determined based on measurements of a patient’s blood oxygen levels. 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. a probe. The stored oxygen can then be used by the patient when needed and is readily replenished. and carbon dioxide levels are measured. which can be refilled at pharmacies or by delivery services. When it is released under pressure from cold storage. In pulse oximetry. generally placed over the end of a finger. Oxygen is usually administered in controlled amounts per minute. Large stationary and small portable gas cylinders can be used in the hospital or the home. Oxygen turns to liquid only when it is kept at very cold temperatures. 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. blood is drawn from an artery.
if they are not secured and stored 217 . a chronic disorder affecting infants. a response that is amplified in the presence of excess oxygen. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. Also. Likewise. it does not appeal to some patients. HBOT is associated with an increased risk of barotrauma of the ear. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. However. leading to the damage of healthy tissues. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. adverse physiological effects may ensue if the flow rate is too high. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. such as with the drug bleomycin. In general. If oxygen flow rate is too low. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. Excess oxygen flow also can result in conditions such as barotrauma. oxygen therapy does not alter the progression of lung disease. Compressed-gas cylinders present a significant safety hazard in the home as well. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD. Bronchopulmonary dysplasia. For example.7 Approaches to Respiratory Evaluation and Treatment 7 that are carrying oxygen. For example. which can lead to tissue dysfunction and cell death.
which has been found to be more effective than the manual methods used in the past. Such techniques. throat. Likewise. strangulation. lifts the lower jaw forward and upward to open the air passage. can prevent some deaths from drowning. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. The person using mouth-to-mouth breathing places the victim on his back. they may cause explosions. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. 218 . establishing and maintaining an open air passage from the upper respiratory tract (mouth. if applied quickly and properly. suffocation. candles. and electric shock. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. and pharynx) to the lungs and 2. clears his mouth of foreign material and mucus. or other sources of ignition. Furthermore. carbon monoxide poisoning. 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. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. choking. oxygen can readily spread fire. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial.
7 Approaches to Respiratory Evaluation and Treatment 7 Mouth-to-mouth breathing is the most effective means of manual artificial respiration. Stockbyte/Getty Images 219 .
and spleen. a needle is inserted through the chest wall and into the effusion site in the pleural space. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. tumours. The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. including the lungs. such as chest X-rays or computerized axial tomography chest scans. liver. Thoracentesis Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space.7 The Respiratory System 7 and clamps the nostrils. and lung infections. permitting the victim to exhale. including heart failure. He then alternately breathes into the victim’s mouth and lifts his own mouth away. the results of chest percussion and imaging tests. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. particles such 220 . a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. including infectious organisms. For diagnostic applications. In the subsequent thoracentesis procedure. the abnormal accumulation of fluid in the pleural space. as well as to prevent further complications associated with the condition. If the victim is a child. Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion. such as tuberculosis and pneumonia. the rescuer may cover both the victim’s mouth and nose. including pleural empyema. It is most often used to diagnose the cause of pleural effusion. Prior to thoracentesis. Once the needle is inserted. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs.
In its simplest form. which occurs when a needle punctures the lungs. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate. which are suggestive of mesothelioma or lung cancer. gas embolism. Experimental compression chambers first came into use around 1860. coagulopathy). Air. carbon monoxide poisoning. Thoracentesis is contraindicated in persons with bleeding disorders (i. tissue injury arising from radiation therapy for cancer. Minor complications associated with thoracentesis include pain and cough. 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. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. Pressures 221 . particularly upon detection of cancerous cells. another breathing mixture. More serious complications include pneumothorax.7 Approaches to Respiratory Evaluation and Treatment 7 as asbestos. gas gangrene resulting from infection by anaerobic bacteria. the accumulation of air in the pleural space. for several hours afterward patients are often observed for the manifestation of adverse effects.e. leading to a drop in blood pressure and fainting (syncope). generally lasting about 10 to 15 minutes. also known as a decompression chamber (or recompression chamber). Thoracentesis is a relatively quick procedure.. However. and wounds that are difficult to heal. and tumour cells. Hyperbaric Chamber A hyperbaric chamber. and aberrant stimulation of the vasovagal reaction. The results of these analyses frequently warrant further diagnostic testing. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks.
which increases oxygen availability to the body in therapeutic treatment.5 to 3 times higher than ordinary atmospheric pressure. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. Chris McGrath/ Getty Images used for medical treatment are usually 1. 222 . 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. for example. In the treatment of carbon monoxide poisoning. In the treatment of decompression sickness. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen).7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment.
survival at one year has been reported at 90 percent. Because transplantation offers the only hope for persons with severe lung disease. often have also suffered lung injury or lung infection. Persons severely disabled by cystic fibrosis. who may be relatively young. conclusion In the 21st century. but from the late 1970s bilateral lung transplantation had some striking results. for example. emphysema. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. which presumably would leave the lungs intact. sarcoidosis. pulmonary fibrosis. With proper selection of donor organs and proper transplantation technique.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. 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. 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. 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 . many people who die of severe head injuries. the techniques are being pursued aggressively in specialized centres.
basic knowledge of the viruses that cause the common cold eluded scientists. which are the most frequent cause of the common cold. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. sometimes drastically increasing their ability to infect and cause disease in humans. and similar preventable respiratory afflictions. in 2009 researchers reported having mapped the genetic codes of rhinoviruses. and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. 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. mesothelioma. acquiring genetic mutations that alter their infectious characteristics. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. However. with health and environmental concerns at the forefront. In many countries. 224 . The negative influence of behaviours such as tobacco smoking on lung function is now well documented.7 The Respiratory System 7 respiratory system. For decades. Influenza viruses circulate globally. Such progress promises to reduce the global mortality of lung cancer. In fact. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations.
In addition. the identification of disease-associated metabolic changes within cells and tissues has played an important role in the development of various functional and diagnostic tests. 225 .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. As researchers and physicians continue to uncover new information about the human respiratory system. For example. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. as well as new treatments. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests.
hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. or transformation of glucose into energy.GLOSSARY apnea Cessation of breathing. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. glottis A sagittal slit formed by the vocal cords. hypercapnia Excess carbon dioxide retention. epiglottis Cartilaginous. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. controls the traffic of air and food. during the act of swallowing. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. glycolysis Fermentation. convection The transfer of heat by movement of a heated fluid such as air or water. Also known as a decompression chamber or recompression chamber. functions as a lid to the larynx and. Act on the larynx as a whole. moving it upward or downward. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. 226 . hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. leaf-shaped flap.
metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body.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. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. paranasal sinuses Cavities in the bones that adjoin the nose. pleura In humans. resulting in the development of secondary tumours. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. length. surfactant Substance that. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. reduces its surface tension. thereby increasing its spreading and wetting properties. neuraminidase A glycoprotein on the surface of influenza viruses. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung. purulent Pus-producing. rhinitis Inflammation of the mucous tissue of the nose. and as the organ of phonation. 227 . when added to a liquid. and tension of the vocal cords. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. a thin membranous sac encasing each lung.
Abnormal breathing during sleep is covered by Nicholas A. 2nd ed. 4 vol. The Physiology and Medicine of Diving. 2nd ed. Fishman and Jack A. (2001).. The effects of swimming and diving on respiration are detailed in Peter B. Christie. a detailed text on impairment of lung function caused by disease. Hlastala and Albert J. Saunders and Colin E. 2nd. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P.. Bennett and David H. Berger. Fishman’s Pulmonary Diseases and Disorders. The human respiratory system is described in David V. Physiology of Respiration. The Respiratory System (2003).). 1 also available in a 3rd ed. ed. Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. (1993). Pack (eds. Control of breathing is described in Murray D. (1971).BIBLIOGRAPHY Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. Diagnosis of Diseases of the Chest. Regulation of Breathing. (1988). (1995). Bates. (1994).). Corwin Hinshaw and John F. Macklem. Fraser et al. 2nd ed. and Ronald V. with vol. 4th ed. H. Elias. 228 . Sullivan (eds. 4th ed.).). Murray. Dempsey and Allan I. and Robert G. and Michael P. 2nd ed. 4th ed. (2008). Control of Breathing in Health and Disease (1999). Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. Altose and Yoshikazu Kawakami (eds. Elliott (eds. (1977–79). and Jerome A. Sleep and Breathing. HighAltitude Medicine and Pathology. (1995). Peter T.
(1981). Pulmonary Diseases and Disorders. 2nd ed. is a general textbook covering diagnosis and treatment of chest diseases. 3rd ed. Nadel (eds.). 3rd ed. Textbook of Respiratory Medicine. Scadding and Gordon Cumming (eds. Respiratory Diseases. provides a comprehensive overview of pathophysiology as related to clinical syndromes. 3rd ed. Principles of Pulmonary Medicine. Fishman (ed. Murray and Jay A. Cameron and Nigel T. see also J. Semple. 229 . (1980). and Andrew M. (1994). Alfred P. Scientific Foundations of Respiratory Medicine (1981).). 4th ed. Respiratory Disorders (1983). Steven E. (1998).7 Bibliography 7 Diseases of the Chest. Bateman. and Ian R. 2nd ed. 3 vol. Comprehensive texts include Gordon Cumming and Stephen J.). G. (2005).. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. Weinberger. 2nd ed. See also John F. (1988). Disorders of the Respiratory System. John Crofton and Andrew Douglas. Thurlbeck’s Pathology of the Lung. (eds. (1980). Churg et al.).
131. 85 artificial respiration. 170–171 Bordet. 217 Bert. 110. 39 alcoholism. 217 bronchoscopy. 113 alkalosis. 124–125. 108. 182. 197 bronchopulmonary dysplasia. 75. Josef. 112–113. 35. 33–34 stem. Jules. 50 Breuer. 171–173 asphyxiation. 91. 171 AIDS. 116. 93. 223 bronchitis. 176. 172. 159.130–131. 197. 208. 209 animals. 168–169. 79–80. 198. 184. 173. 33–34 bronchiolitis. 205–208 brown lung. 103. 52. 181. 188–189 alveoli. 188 bird fancier’s lung. structure of. 152. 100–102. 127. 77 Agricola. 86. 30. 97. 187 anesthesia. 137. 30. 81. 152–156. 174–175 C cancer. 106 bradykinin. Georgius. 74. 38. Paul. 111. 96. 51. 103 anemia. 214 antihistamines. 111 Adam’s apple. 169. 194 asthma. 152. 126 arterial gas embolism. 129. 115. 122. 164. structure and function of. 136.INDEX A acid–base balance. 135. 76. 34–35 amantadine. 107. 193 anthracosis. 48 apnea. 75 acidosis. 137. 94. 184 Actinomyces. 218–220 asbestos. 131–133. 171. 221 asbestosis. 171 antibiotics. 123. 92. 99–100. 81. 210. 160–164. 109. 111. 73. 46. 175. 171–173. 166 black lung. 184–186 altitude sickness. 114. 211. structure and function of. 174 Buerger disease. 189–192. 46. 147. 211. 198 bronchioles. 175. 49 bronchi. 168. 169. 141–144 B barotrauma. 169. 153. 102. 230 . 196. 213 atelectasis. 117. 212–214 aortic body. 134. 52. 169 lung. 159. 127. 42. 186. 118–119 air–blood barrier. structure of. 27 adenosine triphosphate (ATP). 187 byssinosis. 28–29 bronchiectasis. 30. 64.
98–99 epinephrine. 187. 143. 190 histamine. 74 goblet cells. common. 25. 67 chronic obstructive pulmonary disease (COPD). 197. 138. 34 cold. 119 231 . 132. 58–59. 183 hay fever. 137. 193–195. 137. 184. 136–138. 122. 62. 159. 171. 130. 196. 64. 106. 65. 180. 130. 30 Goodpasture syndrome. 183. 52 chloride shift. 190. 158 diffusion limitation. 198. 80. 91. 78. 84. 147. 182. 98–99 cystic fibrosis. 221 cardiopulmonary resuscitation (CPR). 215. 85. 122. 157–158. 63. 192. 189–192. 44. 67. 132 types of. 117. 88–91. 136. 222 decongestants. 127–129. 223 eosinophilic granuloma. 160 HIV. 199. 201. 64. 182 G gas exchange. 129. 213 hemoglobin. 213 cause of.7 Index 181. 218 dyspnea. 183. 188–189. 137. 56. 211–212 diaphragm. 79–81. 102. John Scott. 48. 25. 69. 50. 216–217 Hering. 87. 95. 186. 81–86. 201 F farmer’s lung. 144. 47. 80. 27. 52 Cheyne-Stokes breathing. 209. 130. 191–193 drowning. 151 D decompression sickness. abnormal. 149. 94. Ewald. 158. 81 central nervous system disease. 78. 115. 47. 65. 30. 159. 75–78. 170. 223 7 E emphysema. 150 epiglottis. 112. 105–106. 88 corticosteroids. 175. 211. 166 fungi. 197. 214 diving. 161. 96. 60. 47. 145–148. 50. 46. 133–136. 95. 97. 98. 75. 49 Hering-Breuer reflex. 98–99 epiglottitis. 87. 220. 106. 215 carotid body. 164. 111. 106 glycolysis. 51–52. 221. 177. 156–158. 108. 21. 93. 86. 197–198 H Haldane. 187. 92. 131. 204. 174. 49 high altitudes. 196–197. 72 diphtheria. 94. 156. 215. 135. 212 exercise (training). 198 croup. 217 Clara cells. 207 physiology of. Octave. 98. 81. 164 coughing blood. 210. 190. 98. 84. 50. 145. 66. 122. 168. 69–72 Gengou.
198. 88. 182. 171–173. 147. 221 collapse of. 104 vaccine. 172. 221–222 hypercapnia. 26 232 . 178. 173 cancer of. 125 hypoventilation. 76–77. structure and function of. 76 Monge disease. 69. 196 laryngitis. 113–114.7 The Respiratory System 7 hookworm. 102–105. 92. 152–156. 204. 221 metabolism. 98. 214 leukemia. 159 congestion of. 78 anaerobic. 45. 127. 215. 181. 100 lungs N nephritis. 103 H1N1. 135–136. 26–28 Legionnaire disease. 114–115. 70. 81 mucoviscidosis. 149 influenza. 91. 184–186 hypothyroidism. 143. 184 L Laënnec. 99. 55–56. 87. 150. 176. 199 bird flu. 110. 208 medulla. 38. 117 mesothelioma. 173. 163 hydrothorax. 138–141. 204–205 M measles. 41. 208–209 mediastinum. 169. 81 aerobic. 74. 139. 52. 173. 31 transplantation of. 47. 94 nerves laryngeal. 119 hyperbaric chamber. 68. 93. René-ThéophileHyacinthe. 217 hypoxia. 177 size of. 87. 122. 117. 127 hygiene. 199. 126 hypoxemia. 114. 149. 94. 149. 127. 51–52. 110. 46–48. 38–40 infarction. 26. 156–158. 198. 151. 145 K kidney. 144–145. 166–167 hyperventilation. 190. 215. 223 lung ventilation/perfusion scan. 81 mountain sickness. 74. 138. 138. 31. 99 mediastinoscopy. 209. 95–96 larynx. 37. 83. 129. 50 meningitis. 73–78. 83 hypersensitivity pneumonitis. 167. 197 development of. 50. 44. 141. 186–188 I idiopathic pulmonary fibrosis. 96. 81–82. 103. 128. 178. 49.
122. 38. 128. 114 Pott disease. 114. 211. 92. 214 pertussis. 84. 118 prostaglandins. 154. 93 congestion of. 127–129. 69–71 silicosis. 105–106. 167. 36. 194 pulmonary parenchyma. 88 rimantadine. 139. 33. 170 pneumonia. 169–170 sinuses. 89 structure and function of. 129–130. 152. 21–24. 113. 214–218 128. 223 scarlet fever. 138. 100 rhinoviruses. 95 shunting.7 olfactory. 159. 91–92. 137 oxygen therapy. 52–53. 93. 198 pleural effusion. 126 pleura. 198. 34 pyothorax. 200. 172. 56. 108. 22. 45. 99 Index 7 O obesity. structure and function of. 47 vagus. 110 pulmonary alveolar proteinosis. 22 irrigation of. 106. 149–150. 160 sleep. 220 pleurisy. 136. 87. 93 sinusitis. 155. 220 pneumothorax. 214 pharynx.Wilhelm Conrad. 53. 103. 95. 50 nitrogen narcosis. 44 Pontiac fever. 107. 208. 137. 139. 198. 87. 180. 50. 211. 184. 94. 108. 180–182 pons. 85. 130. 57. 104 osteoporosis. 111 parrot fever. 187 rheumatic fever. 103. 103. 85 nose cilia. 150–151 pulmonary edema. 92–94. 122 function of. 136 233 . 221 pollution. 127. 178. 126 oseltamivir. 208. 125. 19. 107 penicillin. 141. 128 R Relenza. 126. 91. 41. 164 pharyngitis. 108–113. 198 pneumoconiosis. 189. 107–108. 164 inflammation of. 209. 107. 31–32. 173. 92. 103 Röntgen. 131. 124. 168–169. 179 rheumatoid arthritis. 91. 117. 127. 33. 26. 203 P parasites. 126–130. 24–25 pickwickian syndrome. 50 psittacosis. 91. 88. 23–24 sinus. S sarcoidosis. 170. 179–180 Reynaud disease. 214. 126. 87. 146. 104–105 respiratory distress syndrome.
104–105 234 . 69 vestibular folds. 138. 209 swimming. 220–221 thoracic emphyema. 92 streptococcal bacteria. 92. 131–132. 218 sneezing. 163. 97. 92.102. 178. 94 smoking. 58 ventilation–blood flow imbalance. 143. 118. 164. 199. 99. 109. 137. 91. 92. 164 snoring. 136. 130.7 The Respiratory System 7 smallpox. 106. 87. 102. 103. 199. 220 typhoid. 33. 155–156. 94. 94 staphylococci. 111. 153. 78. 97. 110. 172. 88. 123. 146 strep throat. 93. 133–135. 87. 119. 105–107 Z zanamivir. 170. 171. 81–86 syphilis. 127–129 thoracic squeeze. 124 W whooping cough. 53. 129. 183. 95. 122. 214 surgery. 93. 95 tuberculosis. 27–28 T Tamiflu. 99. 91. 56. 25. 104 tetanus. false. 138. 125. 114–121. 97 V vaccination. 208. 96–98 trench mouth. 171. 27–28 vitamin C. 182. 94–95 tonsils. 122. 95. 95. 152. 97. 176. structure and function of. 91. 197. 123–124 sore throat. 21. 128. 173 Valsalva maneuver. 97 smell. 96. 92. 175. 91 vocal chords. 116. 150. 108. 97 trachea. 204. 87. 94–95. 103. 96. 92. 23–24. 192–193 tonsillitis. 106 thoracentesis. 28–30 tracheitis. 107. 97. 130. 164. 198. 53. 103. 138.