Rosen Educational Services materials copyright © 2011 Rosen Educational Services. Respiratory organs—Popular works.E. 228. 87. All rights reserved. Media Acquisition Kara Rogers: Senior Editor. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. p. / nicoolay . All rights reserved. Copyright © 2011 Encyclopædia Britannica.istockphoto. Editorial Technologies Lisa S. Barton: Senior Coordinator. LLC 29 East 21st Street. call toll free (800) 237-9932. New York. Britannica. 196. and the Thistle logo are registered trademarks of Encyclopædia Britannica. © www. I. Chip Somodevilla/Getty Images On pages 19.R467 2011 612. For a listing of additional Britannica Educational Publishing titles. Inc. Rosen Educational Services. Rogers. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. 159. Encyclopædia Britannica.istockphoto. ISBN 978-1-61530-147-8 (library binding) 1. Kara. © www. cm.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. 230: A healthy set of lungs is the powerhouse behind the respiratory system. Luebering: Senior Manager Marilyn L. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. 122. QP121. 60. Inc. Inc. 41. Levy: Executive Editor J. First Edition Britannica Educational Publishing Michael I. / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. 226.2—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. Production Control Steven Bosco: Director.(The human body) “In association with Britannica Educational Publishing.) in association with Rosen Educational Services. NY 10010.” Includes bibliographical references and index. Distributed exclusively by Rosen Educational Services. Biomedical Sciences Rosen Educational Services Heather M.

CONTENTS Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels. Lymphatic Vessels. and Nerves 36 Lung Development 38 Chapter 2: Control and Mechanics of Breathing 41 Control of Breathing 41 Central Organization of Respiratory Neurons 44 Chemoreceptors 46 Peripheral Chemoreceptors 46 Central Chemoreceptors 48 Muscle and Lung Receptors 49 Variations in Breathing 50 Exercise 51 Sleep 52 32 43 51 .

Circulation. 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 .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.

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 clean air then travels into the deep tissues of the lungs. or throat. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. But there are many treatments to keep the airways free and clear. A thin membranous sac known as the pleura covers the lungs. whether by a viral or bacterial infection or through detrimental habits such as smoking. It also sheds light on how easily a healthy respiratory system can be damaged. They pump vital oxygen through airways and into the bloodstream every second of every day.7 Introduction 7 he human lungs are amazing feats of nature. The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. Here. the cone-shaped passageway leading from the mouth and nose to the larynx. eventually reaching the region where gas is exchanged. Air that passes through the nose travels to the pharynx. However. The larynx is a hollow tube connected to the top of the windpipe. and the left lung has 8 to 10. the air is cleansed and moistened before entering the lungs. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. or voice box. This structure provides humans with the sense of smell while also filtering. warming. Inside the lungs. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. the centre of the respiratory system. air travels through the trachea. humans could not survive on Earth. there are numerous nerves and blood vessels. Without this ability. The right lung has 10 airway segments. the most prominent feature of the lung interior are the many small air passages called 11 T . After passing through the larynx. This book explains the science behind the amazing human respiratory system. and moistening inhaled air. also known as the windpipe.

is an automatic process. the bronchial circulation. which makes exchanging gases easier. The average adult lung has approximately 300 million alveoli. controlled by the brain. The second blood system in the lungs. and to the left atrium of the heart. The act of breathing. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 . through the pulmonary veins. The bronchial circulation is a vital source of nourishment for the lung tissues. comprises the network of blood vessels supporting the conducting airways themselves. the oxygenated blood is pumped to the rest of the body. or respiration. From the heart. which range in diameter from 3 mm (0. through the pulmonary arteries. The tissue compartment supports the air and blood compartments and lets them come into close contact. thereby delivering oxygen and other nutrients to organs distant from the lungs.12 inch) to less than 1 mm (less than 0.7 The Respiratory System 7 bronchioles. the region where oxygen is transferred to the blood and carbon dioxide is removed. The gas-exchange area. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. The first of these. the pulmonary system.04 inch). but still keeps them separate. humans and other animals do not need to actively think about breathing in order for it to happen. and tissue. Lungs also have two distinct blood circulation systems. which look like cells in a honeycomb. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. is made up of three separate compartments for blood. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. Thus. air. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs.

thereby increasing oxygen delivery to tissues and maintaining the body’s acid–base balance. The 13 . In the basic mechanics of breathing. Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. When stimulated. In contrast. during sleep. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. In addition to the types of sensors described above. During exercise.7 Introduction 7 abdomen. others respond to chemical changes in the immediate external environment. metabolic rate slows and therefore respiration rate decreases and oxygen demand is low. One of the most notable features of respiratory control is the way in which neural communication between the body and the brain fine-tunes the rate of breathing in order to keep carbon dioxide pressure in the blood constant. these receptors constrict the airways and cause breathing to become fast and shallow. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. respectively. This response represents the body’s attempt to prevent toxins from entering the lungs. One of the major abdominal muscles involved in breathing is the diaphragm. which are located throughout the body. which functions to move air in and out of the lungs as it contracts and relaxes. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. These effects trigger an increase in respiration rate. there also exist sensors that monitor the muscles that control breathing. air moves in and out of the lungs in response to pressure changes. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. metabolic rate and acid levels in muscle tissue increase.

The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. hiking up during the day and descending down to camp to 14 . but it is assisted by a complex assembly of other muscle groups. which can lead to death. transfer carbon dioxide from and add oxygen to blood. However. The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. an activity that is necessary to supply energy to the cells and the body. Oxygen deprivation. the small air spaces in the lungs. People who live at high altitudes adapt to this decrease in oxygen availability. Respiration.7 The Respiratory System 7 diaphragm is the major muscle that facilitates breathing. oxygen is present at lower levels than it is at low altitudes. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. In adults. can cause the brain and the heart to stop functioning. acclimatization. The oxygen that the alveoli transfer to the blood is then circulated to the heart and the body’s other tissues. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. This exchange of gases takes place over an immense surface area. The main purpose of respiration is to provide oxygen for the body’s cells. even for only a few minutes. At high altitudes. is a gradual process. Without oxygen. and metabolism all work together. Oxygen is used by cells for the breakdown of nutrients. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. during vigorous breathing. in which the body works to more efficiently utilize oxygen in the air. The pulmonary alveoli. cells are unable to function properly. circulation. The amount of air that the lungs pump changes dramatically depending on external or internal conditions.

Tuberculosis is another example of a respiratory disease caused by bacteria. Although bacteria sometimes cause pneumonia. pneumonia was a widespread and notoriously deadly disease. as climbers make their way up the mountain. This enables the body to adjust to the decreased availability of oxygen. it was a leading cause of death. death is caused by drowning.7 Introduction 7 sleep at night. but the blood leaks into the air sacs. the body’s tissues become deprived of oxygen. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. which can lead to high-altitude pulmonary edema. For example. certain viruses and fungi can also cause the disease. bacteria can cause inflammation of the trachea. Essentially. Other common upper respiratory conditions include sore throat and pharyngitis. The 15 . and in the first decade of the 21st century. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. in which the body circulates additional blood to the lungs. Before antibiotics were widely available. Inflammation of respiratory tissues can sometimes be severe and chronic. many people have their tonsils removed after suffering from chronic tonsillitis. because these individuals are unable to defend against infectious organisms. which can arise as a result of infection. In the lower respiratory system. Pneumonia also often affects persons with impaired immune systems. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. which can be particularly dangerous in infants and in the elderly. as well as bacterial pneumonia. In the 18th and 19th centuries. a condition known as tracheitis. If these precautions are not taken.

blood vessels in the lungs burst. in which the collapse of the airways leads to intermittent stoppages in breathing. the primary symptom of which is the production of a thick. headaches.” and thus is used to describe diseases of uncertain origin. The term idiopathic means “of unknown cause. Infection is accompanied by fever. and the infected person coughs up bright red blood. or large cheese-like masses. This process leads to the eventual breakdown of respiratory tissues. chills. Eventually. which may be associated with obesity. resulting in the formation of cavities in the lungs. a strain of influenza virus gives rise to a pandemic. which results in progressive shortness of breath until a person can no longer breathe. It is a highly contagious disease too. For some diseases of the respiratory system. no cause has been identified. snoring is caused by blocked airways. despite extensive research. muscle pains. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. seasonal respiratory illness that is caused by viral infection. Many respiratory conditions arise from noninfectious causes. Every few decades. A severe form of snoring is sleep apnea. One of the best-characterized inherited conditions is cystic fibrosis. Lung cancer can arise as a result of a 16 .7 The Respiratory System 7 tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). Some respiratory diseases are inherited. sticky mucus that blocks the airways and the digestive tract. For example. One example is idiopathic pulmonary fibrosis. Influenza is a common. One of the deadliest influenza pandemics was that of 1918–19. A respiratory disease of major concern in the world today is lung cancer. and stomach pain. which caused between 25 million and 50 million deaths worldwide. Sleep apnea causes affected individuals to awaken periodically through the night. to form.

Scientists are constantly researching and developing new and different treatments for respiratory ailments. however. Today. Many treatments. Breathing problems caused by allergies to environmental conditions are fairly common. 17 . however.7 Introduction 7 variety of factors. and even cockroaches. resulting in an estimated 1. Several vaccines have been developed to prevent illnesses such as influenza. have been around for years and are readily available. although tobacco smoking is the primary cause. Some respiratory diseases arise as a result of occupational. Now. Nasal decongestants and antihistamines are examples of commonly used remedies. which affects coal miners who inhale coal dust for many years. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. most likely resulting from exposure to air pollution. In the early 20th century. The best-known occupational lung disease is black lung. it was still considered rare. tobacco smoke. 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. In addition to vaccines and antivirals. Construction workers and insulators exposed to asbestos often suffer from asbestosis. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. or work. lung cancer is the leading cause of cancer deaths worldwide. particularly pneumonia and tuberculosis. Doctors first described the symptoms of lung cancer in the mid-19th century.3 million fatalities each year. factors. or white lung disease. more than 7 percent of children and 9 percent of adults suffer from asthma. Breathing asbestos can also cause the cancerous condition known as mesothelioma. There is hope for those who suffer from respiratory diseases and disorders.

Treatment may also be based on the results of genetic screening. chemotherapy. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant. As this book shows. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. the human respiratory system is a finely tuned feat of engineering. A healthy set of lungs is nothing to take for granted. .7 The Respiratory System 7 Lung cancer treatments may consist of surgery. and radiation. and the consequences of neglecting or damaging that fragile system can be drastic. which can identify mutations that render some lung cancers susceptible to certain drugs.

and part of the oral cavity. Yet. the bronchioles. the lung. Breathing. These actions encompass not only muscular movements but also cellular and chemical processes. and the alveolar ducts. the stem bronchi. The respiratory system consists of two divisions: upper airways and lower airways. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. is fundamental to survival. it is otherwise an automatic process. such as the intrapulmonary bronchi. and all the airways that branch extensively within the lungs. and though we possess the ability to consciously control the rate of our breathing. just at the top of the larynx (or voice box). supporting this process are a number of complex actions that occur within our bodies. where its delicate tissues are 19 . The upper airway system comprises the nose and the paranasal cavities (or sinuses). The lower airway system consists of the larynx.CHAPTER1 ANATOMY AND FUNCTION OF THE HUMAN RESPIRATORY SYSTEM O ur respiratory system provides us with the fundamental ability to breathe: to inhale and exhale air from our lungs. is located in the thorax (or chest). or respiration. the design of the respiratory systeM The human gas–exchanging organ. the trachea. occurring without our having to think about it. as simple as it is for us to inhale and exhale. the pharynx (or throat).

20 .7 The Respiratory System 7 The lungs serve as the gas-exchanging organ for the process of respiration. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product. Encyclopædia Britannica. called conducting airways. carbon dioxide. protected by the bony and muscular thoracic cage. Atmospheric air is pumped in and out regularly through a system of pipes. Inc.

through which air may be inhaled or exhaled. The muscles expand and contract the internal space of the thorax. the pumping action on the lung. Morphology of the upper airways The nose. and the intercostal muscles of the chest wall play an essential role by generating. is sometimes also considered a part of the upper airways.. which acts as a carrier of gases. Other elements fundamental to the process of respiration include the blood. and it protects against the passage into the lungs of potentially infectious foreign agents. the structures of the upper respiratory tract also have other important functions. and the circulatory system (i. as the main respiratory muscle. whose bony framework is formed by the ribs and the thoracic vertebrae. For respiration. The oral cavity. In addition to fulfilling a fundamental role in respiration. the collaboration of other organ systems is essential. such as enabling the sensation of smell. The diaphragm. sinuses. which pumps blood from the heart to the lungs and the rest of the body. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract.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. the nasal 21 . It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. the heart and the blood vessels). The Nose The nose is the external protuberance of an internal space. the nasal cavity.e. The filtering process is vital to clearing inhaled air of dust and other debris.

and they reach their final size around age 20. Most of their development takes place after birth. and the sphenoid sinus. it is also flooding the nasal cavity. they are called the maxillary sinus. the epithelium. and inferior nasal meatuses. On each side. and inferior turbinate bones (or conchae). the superior. The sinuses are located in four different skull bones: the maxilla. The passageways thus formed below each ridge are called the superior. Correspondingly. ethmoid. 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. frontal. and sphenoid bones. consists principally of two cell types. middle. ciliated and secreting cells. via the nasolacrimal duct.7 The Respiratory System 7 septum. with the lacrimal apparatus in the corner of the eye. they help keep the weight of the skull within reasonable limits. from the lateral wall. The paranasal sinuses are sets of paired single or multiple cavities of variable size. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. the ethmoid sinuses. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. the frontal sinus. Typically. Each canal opens to the face by a nostril and into the pharynx by the choana. The complex shape of the nasal cavity results from projections of bony ridges. which also forms the roof of the oral cavity. and they serve as resonance chambers for the human voice. The sinuses have two principal functions: because they are filled with air. which is the largest cavity. The duct drains the lacrimal fluid into the nasal cavity. This structural design 22 . The floor of the nasal cavity is formed by the palate. middle. Its top cell layer. the mucosa of the nose contains mucus-secreting glands and venous plexuses.

moisten. Encyclopædia Britannica. In the roof of the nose. The vestibule. Two regions of the nasal cavity have a different lining. reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. at the entrance of the nose. a process that saves water and energy. is lined by skin that bears short thick hairs called vibrissae. the olfactory organ with its sensory epithelium checks the quality of the inspired air. the air is dried and cooled. During expiration through the nose. and warm the inspired air.7 Anatomy and Function of the Human Respiratory System 7 Sagittal view of the human nasal cavity. Inc. About two dozen olfactory nerves convey the sensation of smell from the 23 . preparing it for intimate contact with the delicate tissues of the gas-exchange area. They clean.

The upper floor. Inc. In the posterior wall of the Sagittal section of the pharynx. 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 can be divided into three floors. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. the nasopharynx.7 The Respiratory System 7 olfactory cells through the bony roof of the nasal cavity to the central nervous system. is primarily a passageway for air and secretions from the nose to the oral pharynx. The Pharynx For the anatomical description. Encyclopædia Britannica. 24 .

The lower floor of the pharynx is called the hypopharynx. the diaphragm. which is the second–largest hollow space of the body. Lying directly above the larynx. The middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx. the vessels transporting blood between the heart and the lungs. it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx.7 Anatomy and Function of the Human Respiratory System 7 nasopharynx is located a lymphatic organ. a cartilaginous. controls the traffic of air and food. and lungs. The lungs reside within the thoracic cavity (chest cavity). Also residing within the thoracic cavity is the tracheobronchial tree: the heart. The epiglottis. the vertebral column. the pharyngeal tonsil. When it is enlarged (as in tonsil hypertrophy). The first two of these provide a canal for the passage of air to the lungs. which roofs the posterior part of the oral cavity. it may interfere with nasal respiration and alter the resonance pattern of the voice. Its anterior wall is formed by the posterior part of the tongue. trachea. Morphology of the lower airways The major structures of the lower airways include the larynx. functions as a lid to the larynx and. The cavity is enclosed by the ribs. It is delimited from the nasopharynx by the soft palate. and the sternum (or breastbone) and is separated from the abdominal cavity (the body’s largest hollow space) by a muscular and membranous partition. leafshaped flap. while the lungs themselves receive the air and facilitate the process of gas exchange. 25 . the great arteries bringing blood from the heart out into general circulation. during the act of swallowing. and food from the oral cavity is routed to the esophagus directly behind the larynx.

the thyroid cartilage. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. the mediastinum being the space and the tissues and structures between the two lungs. Sound is produced by forcing air through a sagittal slit formed by the vocal cords. most of them minute. interconnected by ligaments and membranes. where it is called the visceral pleura. the muscles must be anchored to a stabilizing framework. The largest cartilage of the larynx. As evidenced by trained singers. as the mediastinal pleura. when it occurs. The chest cavity is lined with a serous membrane. The pleural cavity is the space. 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.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. the heart. this function can be closely controlled and finely tuned. and the great vessels. so called because it exudes a thin fluid. or serum. and as the organ of phonation. between the parietal and the visceral pleura. Control is achieved by a number of muscles innervated by the laryngeal nerves. and over part of the esophagus. the two surfaces tend to touch. For the precise function of the muscular apparatus. is made of two plates fused 26 . This portion of the chest membrane is called the parietal pleura. the glottis. The Larynx The larynx is an organ of complex structure that serves a dual function: as an air canal to the lungs and a controller of its access. The membrane continues over the lung. The laryngeal skeleton consists of almost a dozen pieces of cartilage.

the arytenoid cartilages.7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. The transverse axis of the joint allows a hingelike rotation between the two cartilages. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. At the upper end of the fusion line is an incision. with its narrowest width at the glottis. resembling an organ pipe. made of elastic tissue. Just above the vocal cords. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. Viewed frontally. Behind the shieldlike thyroid cartilage. The vocal ligaments are part of a tube. another large cartilaginous piece of the laryngeal skeleton. has a signet-ring shape. to which it is joined in an articulation reinforced by ligaments. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. the thyroid notch. This mechanism plays an important role in altering length and tension of the vocal cords. the lumen of the laryngeal tube has an hourglass shape. they are also formed by the free end 27 . which has given this structure the common name of Adam’s apple. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. the vocal cords span the laryngeal lumen. They correspond to elastic ligaments attached anteriorly in the angle of the thyroid shield and posteriorly to a pair of small pyramidal pieces of cartilage. Like the true vocal cords. below it is a forward projection. the laryngeal prominence. they follow its tilting movement. The cricoid is located below the thyroid cartilage. the epiglottis is also attached to the back of the thyroid plate by its stalk. Both of these structures are easily felt through the skin. The cricoid. Because the arytenoid cartilages rest upright on the cricoid plate.

and tension of the vocal cords. length. The Trachea and the Stem Bronchi Below the larynx lies the trachea. The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. This space is called the ventricle of the larynx. The muscular apparatus of the larynx comprises two functionally distinct groups. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. the laryngeal space enlarges and forms lateral pockets extending upward. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. The intrinsic muscles act directly or indirectly on the shape. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. and is shorter than the left main bronchus. moving it upward (e. The practical consequence of 28 . The right main bronchus has a larger diameter. The extrinsic muscles act on the larynx as a whole. 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. during high-pitched phonation or swallowing) or downward.g. The intrinsic muscles attach to the skeletal components of the larynx itself. the trachea divides in an inverted Y into the two stem (or main) bronchi. the latter can easily be seen from above with the laryngoscope. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. one each for the left and right lung.7 The Respiratory System 7 of a fibroelastic membrane. an instrument designed for visual inspection of the interior of the larynx. is oriented more vertically.8 inch) wide. The mucosal layer contains mucous glands. At its lower end. The interior of the trachea is lined by the typical respiratory epithelium.

a peripheral. however. and a transitional zone in between. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. The structure of the stem bronchi closely matches that of the trachea. where both functions grade into one another. however. In modeling the human airway tree. it is generally agreed that the airways branch according to the rules of irregular dichotomy. purely gas-exchanging zone. From a morphological point of view. however. Functionally.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. Individual paths. the intrapulmonary airway system can be subdivided into three zones: a proximal. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions. largely determines the internal lung structure. and partly also of the blood vessels penetrating the lung. 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. if the trachea is counted as generation zero. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. purely conducting zone. In irregular dichotomy. it makes sense to distinguish the relatively thick-walled. structural design of the airway tree The hierarchy of the dividing airways. the daughter branches may differ greatly in length and diameter. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. 29 .

This design can be compared to a conveyor belt for particles.7 The Respiratory System 7 The conducting airways comprise the trachea. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. rhythmic beat directed outward. gain their stability from their structural integration into the gas-exchanging tissues. The last purely conductive airway generations in the lung are the terminal bronchioles. and the bronchioles. the bronchi. Distally. the two stem bronchi. where they are swallowed. the walls of the bronchioles. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. within which the cilia exert a synchronized. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. devoid of cartilage. and indeed the mechanism is referred to as the mucociliary escalator. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. as does the frequency of goblet cells. After several generations of such respiratory bronchioles. Ciliated cells are present far down in the airway tree. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. In larger airways. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. their height decreasing with the narrowing of the tubes. In the alveoli. The epithelium is covered by a layer of low-viscosity fluid. this fluid layer is topped by a blanket of mucus of high viscosity. 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. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. the alveoli are so densely packed along the airway that an airway wall 30 . moisten.

The right and left lungs are slightly unequal in size. middle. and nerves enter or leave the lungs. smaller in volume because of the asymmetrical position of the heart. which corresponds to a connective tissue space containing the heart. and the thymus gland. and the airway consists of alveolar ducts. the trachea with the stem bronchi. the lungs occupy most of the intrathoracic space. Medially. In humans each lung is encased in a thin membranous sac called the pleura. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. separated from each other by a deep horizontal and an oblique fissure. The parietal pleura and the visceral pleura that line the inside 31 . they are connected with the mediastinum at the hilum. major blood vessels. a circumscribed area where airways. The right lung represents 56 percent of the total lung volume and is composed of three lobes. while their apexes extend above the first rib. The final generations of the airway tree end blindly in the alveolar sacs. the lungs Humans have two lung organs.7 Anatomy and Function of the Human Respiratory System 7 proper is missing. The left lung. has only two lobes separated by an oblique fissure. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. a right and a left. blood and lymphatic vessels. In the thorax. a superior. The space between them is filled by the mediastinum. Gross Anatomy Together. the two lungs rest with their bases on the diaphragm. the esophagus. and inferior lobe.

A thin film of extracellular fluid between the pleurae enables 32 . During inspiration. and diaphragmatic pleurae. the parietal pleura can be subdivided into three portions: mediastinal. are in direct continuity at the hilum. The presence of pleural recesses form a kind of reserve space. so the pleural cavity is larger than the lung volume. Although the hilum is the only place where the lungs are secured to surrounding structures. of the thoracic cavities and the lung surface. Inc. the recesses are partly opened by the expanding lung.7 The Respiratory System 7 Anatomy of the human lungs. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. costal. respectively. Depending on the subjacent structures. Encyclopædia Britannica. thus allowing the lung to increase in volume.

the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics. This outer fibrous layer contains. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. 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. 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. Furthermore.7 Anatomy and Function of the Human Respiratory System 7 the lungs to move smoothly along the walls of the cavity during breathing. If air enters a pleural cavity (pneumothorax). If the serous membranes become inflamed (pleurisy). the lung immediately collapses owing to its inherent elastic properties. There are 10 segments in the right lung and 8 to 10 segments in the left lung. Unlike the lobes. Bronchioles are 33 . the arterial supply follows the segmental bronchi. depending on the classification. The Bronchi and Bronchioles In the intrapulmonary bronchi. and breathing is abolished on this side. besides lymphatics and nerves. and the surgeon can remove single diseased segments instead of whole lobes. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. the pulmonary segments. respiratory movements can be painful. Pulmonary Segments The lung lobes are subdivided into smaller units.

through the 160 square metres (about 1. while the supplying structures. alveolar sacs. The airways are then called alveolar ducts and. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. The gas-exchange tissue proper is called the pulmonary parenchyma. blood. in the last generation. The walls of the bronchioles lack cartilage and seromucous glands. On average. lymphatics. the frequency of alveolar outpocketings increases rapidly. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. conductive airways. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. The respiratory gases diffuse from air to blood. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. the whole wall is formed by alveoli.7 The Respiratory System 7 small conducting airways ranging in diameter from three to less than one millimetre. with a 34 . The bronchiolar wall also contains a well-developed layer of smooth muscle cells. and non-capillary blood vessels belong to the non-parenchyma. Whereas air and blood are continuously replenished. which produce secretions. and tissue. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells.722 square feet) of internal surface area of the tissue compartment. They are polyhedral structures. an adult human lung has about 300 million alveoli. Distally. The Gas-Exchange Region The gas-exchange region comprises three compartments: air. until after two to four generations of respiratory bronchioles. capable of narrowing the airway. and vice versa.

The interalveolar septum is covered on both sides by the alveolar epithelial cells. squamous cell type. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. The type I cells form. These granules are the conspicuous ultrastructural features of this cell type. or cell debris originating from cell damage or normal cell death. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. Ultimately. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. the pulmonary surfactant. more cuboidal cell type. It contains a dense network of capillaries. and a skeleton of connective tissue fibres. covers the remaining surface. is common to two adjacent alveoli. On top of the epithelium. the alveolar macrophages are derived from the bone marrow. and their cell bodies abound in granules of various content. It contains connective tissue and interstitial 35 . the thin air–blood barrier for gas exchange. They are large cells. called the interalveolar septum. together with the endothelial cells. a second. whereas type II cells are secretory. and their task is to keep the air–blood barrier clean and unobstructed. Type II pneumocytes produce a surface-tension-reducing material. and open on one side. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. partly foreign material that may have reached the alveoli. covers between 92 and 95 percent of the gas-exchange surface. A thin. alveolar macrophages creep around within the surfactant fluid. the type I pneumocyte. the smallest of the blood vessels. Before it is released into the airspaces. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing. the type II pneumocyte.7 Anatomy and Function of the Human Respiratory System 7 diameter of about 250 to 300 micrometres. where they connect to the airway. The alveolar wall.

following relatively closely the course of the dividing airway tree. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. Blood Vessels. low in oxygen content but laden with carbon dioxide. amorphous ground substance. to prevent the accumulation of extracellular fluid in the interalveolar septa. is carried from the right heart through the pulmonary arteries to the lungs. are much flimsier than systemic arteries of corresponding size. Because intravascular pressure determines the arterial wall structure. As a consequence. On each side. and proper functioning of the lung is severely jeopardized. The connective tissue comprises a system of fibres. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. which seem to be endowed with contractile properties. an excess of fluid accumulates in the lung tissue and within the airspaces. alternatively. Blood. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. This pathological condition is called pulmonary edema. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. Lymphatic Vessels.7 The Respiratory System 7 fluid. The oxygenated blood from the capillaries is collected by 36 . and cells (mainly fibroblasts). After numerous divisions. the lung is a complex organ. the respiratory gases must diffuse across longer distances. and Nerves With respect to blood circulation. The fibroblasts are thought to control capillary blood flow or. the pulmonary arteries. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. which have on average a pressure five times lower than systemic arteries.

originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. however. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. Within the lung and the mediastinum.7 Anatomy and Function of the Human Respiratory System 7 venules and drained into small veins. The bronchial arteries originate from the aorta or from an intercostal artery. They are small vessels and generally do not reach as far into the periphery as the conducting airways. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. called bronchomediastinal trunks. With a few exceptions. 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. Generally. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. Small bronchial veins exist. Most of their blood is naturally collected by pulmonary veins. Finally. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. 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. Lymph drainage 37 . The superficial. they end several generations short of the terminal bronchioles.


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.

Lung Development
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.


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

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. they also complicate the regulation of breathing. the size of the airway.7 The Respiratory System 7 swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. the force of respiratory muscle contraction. such as speaking. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. such as the airway narrowing that occurs in an asthmatic attack. 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. chewing and swallowing. and the extent of muscle shortening. and muscles such as the scalene and sternocleidomastoid that attach both to the ribs and to the cervical spine at the base of the skull also play an important role in the exchange of air between the atmosphere and the lungs. Mechanoreceptors monitor the expansion of the lung. Although the diaphragm is the major muscle of breathing. These same muscles are used to perform a number of other functions. and maintaining posture. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement. In addition. breathing can be 42 . Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. Intercostal muscles inserting on the ribs. abdominal muscles.

com 43 . Shutterstock.7 Control and Mechanics of Breathing 7 Singing demands a strong diaphragm to control breath.

a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. in turn they drive cranial motor neurons. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . 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. Neurally. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. allowing the activity of these physiological systems to be coordinated with respiration. which supply the diaphragm and other thoracic and abdominal muscles. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath.

which produces lung expansion. Offswitch neurons in the medulla terminate inspiration. is called apneustic breathing. breathing is characterized by prolonged inspiratory activity that may last for several minutes. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. After a gap of a few milliseconds. early inspiratory. offswitch. but at a much lower level. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. This increase in activity.7 Control and Mechanics of Breathing 7 abruptly. As the activity of the post-inspiratory neurons subsides. which occasionally occurs in persons with diseases of the brain stem. expiratory neurons discharge and inspiratory neurons are strongly inhibited. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity. and expiratory. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. post-inspiratory. When the vagus nerves are sectioned or pontine centres are destroyed. inspiratory activity is restarted. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. 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. This type of breathing. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. and gradually declines until the onset of expiratory neuron activity. Mechanically. although in upright humans the lower expiratory intercostal muscles 45 . Then the cycle begins again.

Conversely. cheMoreceptors One way in which breathing is controlled is through feedback by chemoreceptors. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. with exercise). During sleep and anesthesia. and central chemoreceptors in the brain. by a 46 . 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. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. 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. There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. too much ventilation depresses the partial pressure of carbon dioxide. Peripheral Chemoreceptors Hypoxia. which restores partial pressures of oxygen and carbon dioxide to their usual levels.7 The Respiratory System 7 and the abdominal muscles may be active even during quiet breathing. for example. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. Moreover. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. more expiratory intercostal and abdominal muscles contract. As expiration proceeds. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). or the reduction of oxygen supply to tissues to less than physiological levels (produced. as the demand to breathe increases (for example.

contain electron-dense vesicles. stimulates the carotid and aortic bodies. as reflected in the size of carotid body signals. a branch of the glossopharyngeal nerve. which. responding more to rapid than to slow changes in the partial pressure of carbon dioxide.7 Control and Mechanics of Breathing 7 trip to high altitudes). 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). The type I cells are arranged in groups and are surrounded by type II cells. unlike type II cells. The type II cells are generally not believed to have a direct role in chemoreception. may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. This arterial blood parameter rises and falls as air enters and leaves the lungs. vasoactive 47 . 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. Microscopically. and the carotid body senses these fluctuations. Acetylcholine. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. The amplitude of these fluctuations. In addition to responding to hypoxia. Fine sensory nerve fibres are found in juxtaposition to type I cells. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls. and neuropeptides such as enkephalins. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. the principal arterial chemoreceptors. the carotid body consists of two different types of cells. catecholamines.

which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. 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. Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide.7 The Respiratory System 7 intestinal peptide. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. ventilation increases nearly linearly. and substance P. 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. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. The aortic bodies located near the arch of the aorta also respond to acute changes in the partial pressure of oxygen. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. which then act on the sensory nerve. Current thinking places these receptors near the undersurface (ventral part) of the 48 . Even if both the carotid and aortic bodies are removed. As the partial pressure of carbon dioxide in arterial blood rises. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. are located within the vesicles. inhaling gases that contain carbon dioxide stimulates breathing.

Stimulation of these receptors. These receptors are particularly important when lung function is impaired. which excites stretch receptors in the airways. monitor changes in the force produced by muscle contraction. 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. Tendon organs. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. Generally. 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. because they can help maintain tidal volume and ventilation at normal levels. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. called spindles. Receptors.7 Control and Mechanics of Breathing 7 medulla. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. Changes in the length of a muscle affect the force it can produce when stimulated. another receptor in muscles. 49 . there is a length at which the force generated is maximal. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure.

For example. When stimulated. these receptors constrict the airways and cause rapid shallow breathing. However. may be to defend the lung against noxious material in the atmosphere. 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. like the stretch receptors. and thus breathing typically becomes lighter. during exercise. helping to preserve tidal volume. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. accelerating the frequency of breathing. the reflex allows inspiratory time to be lengthened. shortens inspiratory times as tidal volume (the volume of air inspired) increases. These receptors are supplied.7 The Respiratory System 7 which send signals to the medulla by the vagus nerve. Variations in breathing Variations in breathing result from changes in metabolic demands in the tissues of the body. Stimulation of irritant receptors also causes coughing. the body’s metabolic rate slows. and prostaglandins. At the opposite end of the spectrum. increased levels of oxygen are needed to fuel muscle function. by the vagus nerve. others (the J receptors) by unmyelinated fibres. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. however. bradykinin. during sleep. When lung inflation is prevented. The most important function of these receptors. This in turn leads to fluctuations in breathing patterns. which inhibits the penetration of injurious agents into the bronchial tree. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. 50 .

because body temperature rises as metabolism increases. A number of signals arise during exercise that can augment ventilation. thus preserving acid–base homeostasis. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide. arterial chemoreceptors. the arterial 51 . Mechanoreceptors. and thermal receptors all work in concert during exercise to enhance ventilation.7 Control and Mechanics of Breathing 7 Exercise One of the remarkable features of the respiratory control system is that ventilation increases sufficiently to keep the partial pressure of carbon dioxide in arterial blood nearly unchanged despite the large increases in metabolic rate that can occur with exercise. and thermal receptors. Shutterstock. Sources of these signals include mechanoreceptors in the exercising limbs.

In slow-wave sleep. after the physicians who first described it. 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. breathing can become quite erratic. how these various mechanisms are adjusted to maintain acid–base balance. but it may entail unstable feedback regulation of breathing. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. It remains unclear. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. whereas in rapid eye movement sleep. with intermittent periods of apnea. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. The effects on ventilatory pattern vary with sleep stage. however. breathing is diminished but remains regular. is called Cheyne-Stokes breathing. body metabolism is reduced. During sleep. 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. This rhythmic waxing and waning of breathing. 52 . Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. 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. Sleep During sleep. 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.

The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. Because atmospheric pressure remains relatively constant. like the tongue and laryngeal adductors. however. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. flow is determined by how 53 . sleep is of poor quality. which increase the likelihood of obstruction. and complaints of excessive daytime drowsiness are common. air is blown from the lungs (expiration). termed sleep apnea syndrome. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways. In some individuals. Many of the upper airway muscles. in males. have normal upper airway anatomy.7 Control and Mechanics of Breathing 7 In addition. Others. When the air pressure within the alveoli exceeds atmospheric pressure. In some persons with sleep apnea syndrome. Because arousal is often associated with the termination of episodes of obstruction. The condition. When the air pressure within the alveolar spaces falls below atmospheric pressure. and the reduced activity of these muscles during sleep may lead to upper airway closure. leading to severe drops in the levels of blood oxygenation. air enters the lungs (inspiration). portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids. undergo phasic changes in their electrical activity synchronous with respiration. the Mechanics of breathing Air moves in and out of the lungs in response to differences in pressure. occurs most commonly in the elderly. this intermittent obstruction occurs repeatedly during the night. Snoring and disturbed behaviour during sleep may also occur. in the newborn. provided the larynx is open. and in the obese.

There is. When the muscles of inspiration relax. Each small increment of expansion transiently increases the space enclosing lung air. A difference in air pressure between atmosphere and lungs is created. Inc. Encyclopædia Britannica. forcing air in and out of the lungs. Alveolar pressure fluctuations are caused by expansion and contraction of the lungs resulting from tensing and relaxing of the muscles of the chest and abdomen. less air per unit of volume in the lungs and pressure falls.7 The Respiratory System 7 The diaphragm contracts and relaxes. much above or below atmospheric pressure the pressure within the lungs rises or falls. therefore. the volume of chest and lungs 54 . and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume.

therefore. 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. 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.7 Control and Mechanics of Breathing 7 decreases. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. In summary. 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. of the force required to keep the lung distended. then. This. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. This negative (below-atmospheric) pressure is a measure. the pleural pressure reflects primarily two forces: 55 . 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. lung air becomes transiently compressed. 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. its pressure rises above atmospheric pressure. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume.

the additional retraction of lung returns the system to its equilibrium position.7 The Respiratory System 7 1. as by a wound or by a surgical incision. This additional muscular force is removed on relaxation 56 . Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. the length of each of which is affected by the other. And were it not for the inward traction of the lungs on the chest and diaphragm. During inspiration. thereby further raising the diaphragm and causing forceful expiration. The lung– chest system thus acts as two opposed coiled springs. When these muscles relax. which are in turn stretched inward by the pull of the lungs. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch. Because the pleural pressure is below atmospheric pressure. these would collapse. the force required to cause airflow in and out of the lung. The Role of Muscles The respiratory muscles displace the equilibrium of elastic forces in the lung and chest in one direction or the other by adding muscular contraction. the force required to keep the lung inflated against its elastic recoil and 2. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. Were it not for the outward traction of the chest on the lungs. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm.

154 cubic inches) per minute in adults. The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. separated by a film of water. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. muscular contraction occurs only on inspiration. The volume in these circumstances is known as the residual volume. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. During ordinary breathing. Pressures 57 . capable of increasing its output 25 times. expiration being accomplished “passively” by elastic recoil of the lung. The respiratory pump is versatile. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. At total relaxation of the muscles of inspiration and expiration.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). such as pieces of glass. 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. 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.

The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles. with no space between the vocal cords). can be raised voluntarily to 400 litres per minute. © www .. Airflow / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1.7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. The beating of cilia (hairline projections) from cells lining the airways 58 .istockphoto. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.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. normally reaching 30 litres per minute in quiet breathing.e.

and seven litres. In fact. Normal lungs. such adherence occasionally does occur and is one of the dreaded complications of premature births.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. however. 59 . 500 millilitres. 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. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. respectively. totaling about 0. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces.

which is needed to support the functions of the body’s various tissues.722 square feet). gas exchange Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. 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. whereas the carbon dioxide is expelled from the alveoli during exhalation. about 0.CHAPTER3 GAS EXCHANGE AND RESPIRATORY ADAPTATION I nhaled air is rich in oxygen. adapt to variations in atmospheric pressure. as well as other organ systems. however. The oxygen is then distributed by the blood to the tissues. the respiratory system. At high altitudes or during activities such as deep-sea diving. 60 . 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. in exchange. The area of the alveolar surface in the adult human is about 160 square metres (1. For inhaled oxygen to reach these tissues.5 micrometre. This process of adaptation is necessary to maintain normal physiological function. or ¹/¹00 of the diameter of a human hair. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and.

com 61 .7 Gas Exchange and Respiratory Adaptation 7 Changes in the atmosphere’s pressure occur when deep-sea diving and require the respiratory system to adapt. Shutterstock.

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.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. Local flows can be increased selectively. in the flow through skeletal muscles during exercise. In a mixture of gases. The partial pressure of a gas in fluid is a measure of its tendency to leave the fluid when exposed to a gas or fluid that does not contain that gas. or mass flow. which in turn is responsive to overall body requirements. The performance of the heart and circula- 62 . but almost equal quantities of the two gases are involved in metabolism and gas exchange. Respiratory gases also move by diffusion across tissue barriers such as membranes. Convection. for example. Diffusion is the primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. as occurs. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. The rapidity of circulation is determined by the output of the heart. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. the partial pressure of each gas is directly proportional to its concentration. caused by differing modes of transport in the blood. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. convection and diffusion.

Plasma. Enough hemoglobin is present in normal human blood to permit transport of about 0. a protein contained within red cells. The curve representing the content of oxygen in blood at various partial pressures of oxygen. which make up 40 to 50 percent of the blood volume in most mammals. Not all of the oxygen transported in the blood is transferred to the tissue cells. 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. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. so less than 2 percent of oxygen is transported dissolved in plasma. transport of oxygen Oxygen is poorly soluble in plasma. the cell-free. Most oxygen is bound to hemoglobin. called the oxygen-dissociation curve.2 ml of oxygen per ml of blood. These systems are present mainly in the red cells.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). In alveoli at sea level. therefore. liquid portion of blood. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin 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. Each iron atom can bind and then release an oxygen molecule. The amount of oxygen 63 . plays little role in oxygen exchange but is essential to carbon dioxide exchange.

At rest. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. of the blood). (Affinity denotes the tendency of molecules of different species to bind to one another. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent.3-DPG result in an increased affinity of hemoglobin for oxygen. Hemoglobin binds not only to oxygen but to other substances as well.3-DPG decrease the affinity of hemoglobin for oxygen. including hydrogen ions (which determine the acidity. carbon dioxide. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. and the oxygen-dissociation curve shifts to the right. 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. with the binding of oxygen. carbon dioxide.) Increases in hydrogen ions. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. as occurs with anemia or extreme exercise. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. or pH. and the curve is shifted 64 .3-DPG. Conversely. and 2. Although these substances do not bind to hemoglobin at the oxygen-binding sites. and 2.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood.3-diphosphoglycerate (2. carbon dioxide. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). Because of this decreased affinity. or 2. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). Reductions in normal concentrations of hydrogen ions. This reserve is available to meet increased oxygen demands.

This displacement increases oxygen binding to hemoglobin at any given partial pressure of oxygen and is thought to be beneficial if the availability of oxygen is reduced. A small portion of carbon dioxide. The remainder is found in reversible chemical combinations in red blood cells or plasma. about 5 percent. with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex.7 Gas Exchange and Respiratory Adaptation 7 to the left. Some carbon dioxide binds to blood proteins. Temperature changes affect the oxygen-dissociation curve similarly. The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. 65 . enhanced release of oxygen). whereas a decrease in temperature shifts the curve to the left (increased affinity). Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. an insufficient time to eliminate all carbon dioxide. Complete elimination would lead to large changes in acidity between arterial and venous blood. so that temperature-associated changes in oxygen affinity have little physiological importance. remains unchanged and is transported dissolved in blood. blood normally remains in the pulmonary capillaries less than a second. The range of body temperature usually encountered in humans is relatively narrow. An increase in temperature shifts the curve to the right (decreased affinity. principally hemoglobin. to form a compound known as carbamate. as occurs at extreme altitude. Furthermore.

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. which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-). a protein enzyme present inside the 66 . it combines with water to form carbonic acid (H2CO3 ). As carbon dioxide enters the blood.7 The Respiratory System 7 Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water. a relatively weak acid. Blood acidity is minimally affected by the released hydrogen ions because blood proteins.) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. inactivating them. are effective buffering agents. especially hemoglobin. Shutterstock. Carbonic anhydrase. (A buffer solution resists change in acidity by combining with added hydrogen ions and. essentially.

release of oxygen in body tissues enhances binding of carbon dioxide as carbamate.7 Gas Exchange and Respiratory Adaptation 7 red blood cell. The simultaneous exchange of these two ions. 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. A few amino sites on hemoglobin are oxylabile. that is. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. 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. where the partial pressure of carbon dioxide is lower than in the blood. then transported to the plasma. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change 67 . while 62 percent exists as bicarbonate in plasma. The change in molecular configuration of hemoglobin that accompanies the release of oxygen leads to increased binding of carbon dioxide to oxylabile amino groups. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. however. Because the enzyme is present only inside the red blood cell. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. known as the chloride shift. A reverse sequence of reactions occurs when blood reaches the lung. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. Thus. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. The bulk of bicarbonate ions is first produced inside the cell.

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 almost all blood entering the lungs participates in gas exchange. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs.7 The Respiratory System 7 or binding. because only free carbon dioxide easily crosses biologic membranes. blood flow through the lung is continuous. because of the increased size of inspired breaths. In contrast to the cyclic nature of ventilation. yet this pool is important. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 . Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. 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. not all inspired air participates in gas exchange. Between these two events. Under ideal circumstances. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. gas exchange in the lung The introduction of air into the alveoli allows the removal of carbon dioxide and the addition of oxygen to venous blood. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. In health. most carbon dioxide is transported as bicarbonate or carbamate.

but the level of carbon dioxide in arterial blood is not elevated even 69 . venous blood enters the bloodstream without passing through functioning lung tissue. If the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange—a condition known as hypoventilation—the alveolar partial pressure of carbon dioxide rises and the partial pressure of oxygen falls almost reciprocally. In shunting. Because of the differences in oxygen and carbon dioxide transport.g. and limitations of diffusion. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. shunting. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. alveoli filled with fluid or inflammatory material). impaired oxygen exchange is far more common than impaired carbon dioxide exchange. ventilation– blood flow imbalance. 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. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small..7 Gas Exchange and Respiratory Adaptation 7 gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. A reduction in arterial blood oxygenation is seen with shunting.

blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. Because the carbon dioxide–dissociation curve is steep and relatively linear. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. As a result. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. When blood perfusing the collapsed. which is usually achieved without difficulty. The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. As noted earlier. Blood leaving an unventilated area of the lung has 70 . and the composite arterial blood carbon dioxide content remains normal. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. 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 contrast. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. the content of carbon dioxide is greater than the normal carbon dioxide content.7 The Respiratory System 7 though the shunted blood contains more carbon dioxide than arterial blood. 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. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide.

alveoli become either overventilated or underventilated in relation to their blood flow. In the healthy area of the lung. 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. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. 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. which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. Inspired air and blood flow normally are distributed uniformly. therefore. Overventilated alveoli. the amount of carbon dioxide eliminated is increased.7 Gas Exchange and Respiratory Adaptation 7 an oxygen content that is less than the normal content. in the arterial blood. The oxygen-dissociation curve. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. Thus. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. a plateau is reached at the 71 . In alveoli that are overventilated. reaches a plateau at the normal alveolar partial pressure. however. and an increase in blood partial pressure results in a negligible increase in oxygen content. and each alveolus receives approximately equal quantities of both. 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. cannot compensate in terms of greater oxygenation for underventilated alveoli because. however.

72 . and decreased time available for exchange due to increased velocity of flow. In disease. These factors are usually grouped under the broad description of “diffusion limitation.7 The Respiratory System 7 alveolar partial pressure of oxygen. loss of surface area available for diffusion of oxygen. which facilitates carbon dioxide exchange. these include increased thickness of the alveolar–capillary membrane. however. 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. 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 any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. Carbon dioxide exchange. a reduction in the alveolar partial pressure of oxygen required for diffusion. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. the greater the reduction in blood oxygenation. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. A variety of processes can interfere with this orderly exchange. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. For oxygen. and increased ventilation will not increase blood oxygen content.

which set the limit for respiration. To recharge the molecule by adding the third phosphate group requires energy derived from 73 . In the process. Each cell maintains a set of furnaces. The precise object of respiration therefore is the supply of oxygen to the mitochondria. In antiquity and the medieval period. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). 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. such as the contraction of muscle fibre proteins or the synthesis of protein molecules. through the oxidation of foodstuffs such as glucose.7 Gas Exchange and Respiratory Adaptation 7 interplay of respiration. The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. Modern cell biology has unveiled the truth behind the metaphor. the energetic needs of the cells are supplied. whose third phosphate bond can release a quantum of energy to fuel many cell processes. the mitochondria. cells set the demand for oxygen uptake and carbon dioxide discharge. 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. and MetabolisM The interplay of respiration. a molecule with only two phosphate bonds. For gas exchange that takes place in the lungs. 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). circulation. circulation. and metabolism is the key to the functioning of the respiratory system as a whole.

If oxygen supply is interrupted for a few minutes. which requires oxygen and involves the mitochondria. will die. or substrates. For any sustained highlevel cell activity. or even the organism. the aerobic metabolic pathway is therefore preferable. In contrast. aerobic metabolism. Oxygen is collected from environmental air. 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. transferred to blood in the lungs. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. many cells. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion.7 The Respiratory System 7 the breakdown of foodstuffs. and 2. Two pathways are available: 1. and since each cell must produce its own ATP (it cannot be imported). anaerobic glycolysis. because the cells maintain only a limited store of highenergy phosphates and of oxygen. or its need for oxygen. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. Because oxidative phosphorylation occurs only in mitochondria. or fermentation. which operates in the absence of oxygen. whereas they usually have a reasonable supply of substrates in stock. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. It begins with 74 .

In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. more accurately the metabolic rate of the cells. which is determined by its content of hemoglobin in the red blood cells. which is achieved by convection or mass flow of air through an ingeniously branched system of airways. the demand for ATP and oxygen increases linearly with work rate. In the most peripheral airways. and discharge to the cells. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. or. Metabolism. sets the demand for oxygen. This is accompanied by an increased cardiac output. At rest. essentially resulting from a higher heart rate. Blood also serves as carrier for both respiratory gases: oxygen.7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. transport by blood flow. As more and more muscle cells become engaged in doing work. With exercise this rate can be increased more than 10-fold in a normal healthy individual. and carbon dioxide. which is bound to hemoglobin in the red blood cells. which is carried by both plasma and red blood cells and which also serves as a buffer for acid–base balance in blood and tissues. and by 75 . but a highly trained athlete may achieve a more than 20-fold increase. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0.5 micrometre) and the surface area of the barrier. a human consumes about 250 ml of oxygen each minute. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier.

from the lung to the mitochondria. but beyond the aerobic scope they must revert to anaerobic metabolism. mainly lactic acid. but it is not straightforward. such as dogs or horses. Muscle can do more work.7 The Respiratory System 7 increased ventilation of the lungs. based on observations that oxygen consumption rates differ significantly among species. accumulate and limit the duration of work. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. because of the complexity of the system. oxygen consumption per unit body mass increases as animals become smaller. 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. For example. The limit to oxidative metabolism is therefore set by some features of the respiratory system. well below interspecies differences. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. have an aerobic scope more than twofold greater than that of other animals of the same size. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. with the result that waste products. Consequently. 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. the athletic species in nature. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. this is called adaptive variation. the aerobic scope can be increased by training in an individual. Furthermore. Then. a feature called allometric variation. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. 76 .

in all types of variation. 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. the mitochondria increase in proportion to the augmented aerobic scope. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. the muscle cells make more mitochondria. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption.7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. This difference arises from a phenomenon known as adaptive variation. If energy (ATP) needs to be produced at a higher Within the aerobic scope the adjustments are caused by functional variation. 77 . Mitochondria set the demand for oxygen. Shutterstock. For example. 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. If this proves true. such as in training. and the heart can increase in number. the levels of hemoglobin in the blood. It appears. beyond which oxidative metabolism cannot be increased by training. whose capacity to pump blood reaches a limit. whereas the mitochondria. the lung may well constitute the ultimate limit for the respiratory system. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. however. 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. the structure of the alveoli in the lungs.7 The Respiratory System 7 It is thus possible that oxygen consumption is limited at the periphery. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. at the last step of aerobic metabolism. The issue of peripheral versus central limitation is still under debate. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. mainly the heart. both in terms of rate and of the size of the ventricles. In the cases of swimming and diving. the blood vessels. which determines the volume of blood that can be pumped with each stroke. In the case of adaptation to high altitudes. or volume to augment their capacity when energy needs increase. the lung lacks this capacity to adapt. rate. 78 . the blood.

whether undertaken deliberately or not. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. Bishop/National Geographic/Getty Images 79 . Indigenous mountain species such as the At high altitudes. which. both in the ambient air and in the alveolar spaces of the lung. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen. Humans and some other mammalian species. such as cattle. commences from the time of exposure to high altitudes. which heighten the partial pressure of oxygen at all stages. This very fall poses the major respiratory challenge to humans at high altitude. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. Barry C.7 Gas Exchange and Respiratory Adaptation 7 High Altitudes Ascent from sea level to high altitude has well-known effects on respiration.

The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. As the oxygen deprivation persists. such as 2. In addition. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. the size of muscle fibres decreases. 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. the tissues develop more blood vessels. on the other hand. which increases the amount of oxygen transported to the tissues.7 The Respiratory System 7 llama. the carotid bodies enlarge but become less sensitive to the lack of oxygen. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. 80 . from the alveolar spaces in the lung to the mitochondria in the cells. 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. With a prolonged stay at altitude. where oxygen is needed for the ultimate biochemical expression of respiration. as capillary density is increased. which also shortens the diffusion path of oxygen. and. exhibit an adaptation that is heritable and has a genetic basis. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. which takes the form of deeper breathing rather than a faster rate at rest. thought to enhance oxygen perfusion of the lung apices. attached to the division of the carotid arteries on either side of the neck. Diffusion of oxygen across the alveolar walls into the blood is facilitated. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages.3DPG. the carotid bodies. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange.

After living many years at high altitude. and vicuña in the Andes or the yak in the Himalayas are adapted rather than acclimatized to the low oxygen partial pressures of high altitude. and their carotid bodies remain small. They do not develop small muscular blood vessels or an increased blood pressure in the lung. these indigenous. This disease is characterized by greater levels of hemoglobin. Their hemoglobin has a high oxygen affinity. Human respiration requires ventilation with air. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. exhibit a set of responses that may be called a “diving reflex. after the Peruvian physician who first described it. alpaca. some highlanders lose this acclimatization and develop chronic mountain sickness. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the 81 . including humans. Other physiological changes are also observed. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. or benign tumour. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. Swimming and Diving Fluid is not a natural medium for sustaining human life after the fetal stage. sometimes called Monge disease.7 Gas Exchange and Respiratory Adaptation 7 Indigenous mountain animals like the llama.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. all vertebrates. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. Nevertheless. In contrast to acclimatized humans. A chemodectoma.

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. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath.7 The Respiratory System 7 same time that a diver is breathing from an independent gas supply. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. Most hazards result from the environmental pressure of water. but the oxygen content of the blood concurrently falls to unusually low levels. which is 82 . Hyperventilation. Unconsciousness may then occur in or under the water. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. the absolute pressure. as sometimes happens in snorkeling. But this apparent advantage introduces additional hazards. and consciousness remains unimpaired. many of them unique in human physiology. At the depth of a diver. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. Two factors are involved. Hyperventilation can be dangerous. however. but it cannot provide an equivalent increase in oxygen. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. When the accumulated carbon dioxide at last forces the swimmer to return to the surface.

is the vertical hydrostatic pressure gradient across the body. the blood and tissues of the diver. Alveolar oxygen levels can also be disturbed in diving. is the limiting factor for hard physical work underwater. 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. rather than cardiac or muscular performance. the increased density of the respiratory gases. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. often with the formation of bubbles. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. and the consequences of the uptake of respiratory gases into. and their subsequent elimination from. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. the levels of inspired oxygen are 83 . but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia).7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. acting at any depth. Hypoxia may result from failure of the gas supply and may occur without warning. The increased work of breathing. 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. More commonly. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. is one factor. The other factor. This may be compounded by an increased inspiratory content of carbon dioxide.

640 feet) in the sea and more than 680 metres (2.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. it may cause the rapid onset of convulsions. approximately in proportion to the reciprocal of the square root of the increasing gas density.7 The Respiratory System 7 increased. In mixed-gas diving. The use of hydrogen.2 and 0. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic.5 bar (“surface equivalent value” = 150 percent). At a partial pressure greater than 1. which in a mixture with less than 4 percent oxygen is noncombustible. Oxygen in excess can be a poison. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. At the extreme depths now attainable by humans— some 500 metres (1. 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. has the additional advantage of providing a breathing gas of lesser density. 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. like an anesthetic.5 bar. provides a greater respiratory advantage for deep diving. High values of end-tidal carbon dioxide with 84 .

Unless vented. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. which represents the net effect of the external pressures and the effects of chest buoyancy. the expanding gas may rupture alveolar septa and escape into interstitial spaces. in which case more blood will be shifted into the thorax. a condition that. possibly extending into the pericardium or into the neck. The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. places the diver at great risk. And whatever the orientation of the diver in the water. Also.7 Gas Exchange and Respiratory Adaptation 7 only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. Failure to exhale 85 . Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. if it occurs underwater. More seriously. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). has proved useful in designing underwater breathing apparatuses. resulting in less intrathoracic blood volume. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. or it may be effectively greater. This is a major cause of death among divers. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. The concept of a hydrostatic balance point within the chest.

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. 86 .7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. can result in a sometimes life-threatening condition known as decompression sickness.6 feet). even from depths as shallow as 2 metres (6. Other possible causes of pulmonary barotrauma include retention of gas by a diseased portion of lung and gas trapping due to dynamic airway collapse during forced expiration at low lung volumes. Inadequacy of diver decompression. which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure.

however. Examples of severe lower respiratory infections include croup. Legionnaire disease. In most cases. These diseases may be caused by a variety of agents. and molds. upper respiratory infections include the common cold. and may be highly contagious. various types of pneumonia. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. bacteria. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. whereas lower respiratory infections include laryngitis. Some conditions can cause extensive lung damage. can be effectively treated with prescription antimicrobial drugs. and any condition of the bronchi and lungs. requiring patient hospitalization. whether of the upper or lower respiratory tract. pharyngitis. with this division occurring at the anatomical level of the larynx. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues. resulting in patient isolation.CHAPTER4 INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM I nfectious diseases are among the most common conditions affecting the human respiratory system. tracheitis. infectious diseases. as considered here. including viruses. 87 . and tuberculosis. and tonsillitis. Thus. However. sinusitis.

The viruses start spreading from an infected person before the symptoms appear. Incubation is short. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. or drafts. not from a cold environment. pharynx. influenza. with little or no medication. respiratory syncytial viruses. chilled wet feet. and reoviruses. and may cause secondary infections in the eyes or middle ears. sometimes spreads to the lower respiratory structures. and the 88 . however. Rhinoviruses. 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. Some of these infections may resolve on their own. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract. 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. however. In other cases. The feeling was originally believed to have a cause-and-effect relationship with the disease. usually one to four days. More than 200 agents can cause symptoms of the common cold. are the most frequent cause.7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses. and tonsils are frequently the site of both acute and chronic infections. but this is now known to be incorrect. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. including parainfluenza.

This fluid acts to dilute the virus and clear it from the nose. headaches. usually coming into contact with the infectious agents in day care centres or preschools.7 Infectious Diseases of the Respiratory System 7 spread reaches its peak during the symptomatic phase. Symptoms abate as the host’s defenses increase. yellow-green fluid that is full of the debris of dead cells. The sensory organs in the nose are stung by the inflammatory reaction. sore throat. Coughing can be dry or produce amounts of mucus. Once a virus becomes established on the respiratory surface of the nose. but it is possible to take a culture for viruses. its activities irritate the nose’s cells. Young children can contract between three and eight colds a year. but in the individual the same symptoms tend to recur in succeeding bouts of infection. If the virus penetrates more deeply into the upper respiratory tract. Symptoms may include sneezing. It may result from the greater amount of time spent indoors. but lingering cough and postnasal discharge may persist for two weeks or more. There is no effective antiviral agent available for the common 89 . and nasal discharge. a second method of expelling the virus. which increases the likelihood of close contact with those persons carrying cold viruses. but the reason for this incidence is unknown. Diagnosis of a cold is usually made by medical history alone. and minor epidemics commonly occur throughout the winter. The nasal discharge is the first warning that one has caught a cold. inflammation of the nose (rhinitis). chills. Cold symptoms vary from person to person. fatigue. There is usually no fever. The usual duration of the illness is about five to seven days. the clear fluid often changing to a thick. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. thereby setting up sneezing. which respond by pouring out streams of clear fluid. The incidence of colds peaks during the autumn.

fatigue. but it can comprise sneezing. sore throat. headaches. rhinitis. the common cold does not involve a 90 . chills. Shutterstock. and nasal discharge.7 The Respiratory System 7 Usually.

Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. a result of irritation by foreign objects or fumes. In many studies. or a reaction to certain drugs. For a viral sore throat. fungi. viruses. administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. uvula. soft palate. Sore Throat Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). Generally. the throat reddens. mycoplasmas. and nasal congestion. and the tonsils may secrete pus and become swollen. fever. Pharyngitis Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. In treating nonviral sore throat. as are antiseptic gargles. antibiotics are often effective. and parasites and by recognized diseases of uncertain causes. Inflammation usually involves the nasopharynx. which typically subside after one week. 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.7 Infectious Diseases of the Respiratory System 7 cold. Infection by 91 . The illness can be caused by bacteria. A sore throat may be a symptom of influenza or of other respiratory infections. Therapy consists of treating the symptoms: relieving aches. and tonsils. treatment is aimed at relieving symptoms. 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.

Within approximately three days the fever leaves. Viral pharyngitis infections also occur.7 The Respiratory System 7 Streptococcus bacteria may be a complication arising from a common cold. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. 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). Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. They cause fever. If a diagnosis of streptococcal infection is established by culture. extremely sore throat that is felt during swallowing. swelling of lymph nodes. Purulent (pus-producing) sinusitis can occur. sometimes in children there are abdominal pain. diphtheria. Chronic cases caused by irritants in the environment or by 92 . however. usually with penicillin. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. headache. including tuberculosis. is instituted. and the cause of pharyngeal inflammation can be determined by throat culture. Lymphatic tissue in the pharynx may also become involved. appropriate antibiotic therapy. and a slight fever. but the other symptoms may persist for another two to three days. a pustulant fluid on the tonsils or discharged from the mouth. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. nausea. A number of other infectious diseases may cause pharyngitis. and irritability. headache. and sore throat that last for 4 to 14 days. and meningitis. requiring treatment with antibiotics. Diagnosis is established by a detailed medical history and by physical examination. syphilis.

Streptococcus pneumoniae. keeping the sinuses clean. It may also be caused by allergy to agents 93 . The origin of acute sinus infection is much like that of ear infection. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. the pus localized in any individual sinus may have to be removed by means of a minor surgical procedure known as lavage. The organisms usually involved are Haemophilus influenzae. but the adjacent mouth and nose have a varied bacterial flora.7 Infectious Diseases of the Respiratory System 7 impaired immune systems may require more extended treatment. On physical examination. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. and sinus tenderness. Common symptoms include facial pain. 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. Under normal conditions. persons with sinusitis are usually found to have an elevation in body temperature. Streptococcus pyogenes. Following a common cold. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. If the infection persists. infection can be established. and fever following previous upper respiratory viral illness. Staphylococcus aureus. including surgery. When ciliary function is damaged. nasal discharge. headache. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. Chronic sinusitis may follow repeated or neglected attacks of acute sinusitis. Normally the middle ear and the sinuses are sterile. and many other penicillin-sensitive anaerobes.

sinuses. and sometimes headache. fever. Tonsillitis Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. repeated or persistent sore throat. and enlarged lymph nodes on both sides of the neck. malaise. The symptoms of chronic sinusitis are a tendency to colds. difficulty in swallowing. The treatment includes bed rest until the fever has subsided. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. obstructed breathing. Pain is not a feature of chronic sinusitis. Repeated acute infections may cause chronic inflammation of the tonsils. loss of smell. resulting in a peritonsillar abscess. such as fungi or pollen. The symptoms are sore throat. and bronchi. virulent bacteria may spread from the infected tonsil to the adjoining tissues. Locally. The infection may extend upward into the nose. and ears or downward into the larynx. In severe cases endoscopic surgery may be necessary to remove obstructions. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. isolation to protect others from the infection. The 94 . The infection lasts about five days. If antibiotic therapy or repeated lavage do not alleviate the condition. with or without heart involvement. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. and swollen lymph nodes in the neck. purulent nasal discharge. trachea.7 The Respiratory System 7 in the environment. and warm throat irrigations or gargles with a mild antiseptic solution. usually hemolytic streptococci or viruses. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. evidenced by tonsillar enlargement.

tuberculous. is associated with a high rate of death in infants and the elderly. Laryngitis Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. or sulfur dioxide can also cause severe inflammation. and contains many 95 . the infectious disease tuberculosis. diphtheria. Laryngitis is classified as simple. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. secretes a thick mucous substance. in order to prevent potentially disabling damage to lung tissue. Likewise.7 Infectious Diseases of the Respiratory System 7 treatment in this case is surgical removal (tonsillectomy). which is a major cause of lung disease globally. Simple laryngitis is usually associated with the common cold or similar infections. or syphilitic. Usually the mucous membrane lining the larynx is the site of prime infection. in trench mouth. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. steam. Nonbacterial agents such as chlorine gas. involving long-term antimicrobial therapy. diphtheritic. pneumonia. Scarlet fever. and trench mouth may also produce acute tonsillitis. Thus. For example. In diphtheria the tonsils are covered with a thick. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. adherent membrane. It becomes swollen and filled with blood. with a grayish membrane that wipes off readily. whitish. lower respiratory systeM infections Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions.

small lumps of tissue that project from the surface. Syphilitic laryngitis is one of the many complications of syphilis. or overuse of the vocal cords. The wall of the larynx may thicken and become inflamed. they may consolidate at the vocal cords and cause an obstruction there. shorten the vocal cords. As the disease advances to the third stage. A similar type of membrane covering can occur in streptococcal infections. fibrin (blood clotting protein). Tracheitis Tracheitis is an inflammation and infection of the trachea. Tubercular nodule-like growths are formed in the larynx tissue. In the second stage of syphilis. leaving ulcers on the surface.7 The Respiratory System 7 inflammatory cells. and suffocation may result. The scars can distort the larynx. When the epiglottis. Most conditions that affect the trachea are bacterial or 96 . alcoholism. sores or mucous patches can form. When looser portions of this false membrane become dislodged from part of the larynx. tissue destruction is followed by healing and scar formation. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. There may be eventual destruction of the epiglottis and laryngeal cartilage. The bacteria die after infecting the tissue. the larynx can become obstructed. and diseased skin cells to attach to and infiltrate the surface mucous membrane. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. It may cause a membrane of white blood cells. which closes the larynx during swallowing. Chronic laryngitis is produced by excessive smoking. The mucous membrane becomes dry and covered with polyps. and produce a permanent hoarseness of the voice. becomes swollen and infected by influenza viruses.

7 Infectious Diseases of the Respiratory System 7 viral infections. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. Acute infections occur suddenly and usually subside quickly. tuberculosis. and staphylococci. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. and swelling of the mucous membrane lining the trachea. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. Neisseria organisms. Chronic infections recur over a number of years and cause progressive degeneration of tissue. hemorrhages. sulfur dioxide. and the walls thicken because of an increase in elastic and muscle fibres. Common bacterial causes of acute infections are pneumococci. pustules and ulcers. Irritants such as heavy smoking and alcoholism may invite infections. The infections produce fever. although irritants like chlorine gas. The mucous glands may become swollen. Diphtheria usually involves the upper mouth and throat. streptococci. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. but the trachea may also be attacked. Diphtheria. Typhoid causes swelling and ulceration in the lymph tissue. In smallpox. Blood vessels increase in number. smallpox. and syphilis all afflict the trachea. Infections may last for a week or two and then pass. fatigue. The walls of the trachea during chronic infection contain an excess of white blood cells. and small polyplike formations occasionally grow. they do not cause significant damage to the tissue unless they become chronic. Degenerated tissue is eventually replaced by a fibrous scar tissue. Intense blood congestion. such as those that occur on the external skin. form in the mucous membrane. and degeneration of the tracheal tissue can occur. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. Syphilis forms lesions that erode the 97 . Generally.

and they strike most frequently in late fall and winter. Generally. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. In some cases. making it necessary for the patient to sit and lean 98 . and can cause thickening and stiffening of the spaces between the cartilage. spasms of the laryngeal muscles. Such infections are most prevalent among children younger than age three. the onset of viral croup is preceded by the symptoms of the common cold for several days. inflammation occurs around the bronchial tree. the most frequent being those with the parainfluenza and influenza viruses.7 The Respiratory System 7 tissue. It is characterized by marked swelling of the epiglottis. The symptoms are caused by inflammation of the laryngeal membranes. hoarseness. Because of the marked swelling of the epiglottis. Viral infections are the most common cause of croup. Bacterial croup. It is most often caused by an infection of the airway in the region of the larynx and trachea. is a more serious condition that is often caused by Haemophilus influenzae type B. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. with high fever and breathing difficulties. hospitalization may be necessary. In cases of severe airway obstruction. Croup Croup is an acute respiratory illness of young children that is characterized by a harsh cough. Some cases result from allergy or physical irritation of these tissues. and difficult breathing. there is obstruction at the opening of the trachea. also called epiglottitis. Epinephrine and corticosteroids have also been used to reduce swelling of the airway. or inflammation around the trachea. The onset is usually abrupt.

Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. resulting usually in a relatively brief disease called acute infectious bronchitis. which generally relieve the inflammation within 24 to 72 hours. however. Patients are given antibiotics. In addition. The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. An artificial airway must be opened. ammonia. and measles. influenzae. through which air passes into the lungs. Therefore. Children with epiglottitis require prompt medical attention. it is often part of the common cold and is a common sequel to influenza. Epiglottitis generally strikes children between ages three and seven. Infectious Bronchitis Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. It is most frequently caused by viruses responsible for upper respiratory infections. Under ordinary circumstances. organisms do enter the airways and initiate a sudden and rapid attack. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. whooping cough. preferably by inserting a tube down the windpipe. Acute bronchitis can also be caused by bacteria such as Streptococcus. or organic solvents.7 Infectious Diseases of the Respiratory System 7 forward to maximize the airflow. particularly in people who have underlying chronic lung disease. Under certain circumstances. 99 . 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.

100 . In isolated cases. or this may develop slowly over time. This pattern of occurrence has only recently been recognized. with complete healing in all but a very small percentage of cases. In adults. an acute bronchiolitis episode is followed by a chronic obliterative condition. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal. acute bronchiolitis of this kind is not a well-recognized clinical syndrome.7 The Respiratory System 7 Treatment of acute bronchitis is largely symptomatic and of limited benefit. though there is little doubt that in most patients with chronic bronchitis. bronchodilators. in whom such a syndrome may follow the acute exposure. called chronic bronchitis. and particularly in infections with respiratory syncytial virus. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. Another form of bronchitis. Bronchiolitis Bronchiolitis refers to inflammation of the small airways. discussed in a later chapter. which results in protracted and often permanent damage to the bronchial mucosa. but it normally clears spontaneously. particularly in children between ages one and two. acute exacerbations of infection are associated with further damage to small airways. is a long-standing. repetitive condition. Steam inhalation. In addition to patients acutely exposed to gases. and expectorants will usually relieve the symptoms. Bronchiolitis probably occurs to some extent in acute viral disorders. In some cases the inflammation may be severe enough to threaten life. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability.

is characteristically not followed by acute symptoms. or in fires involving plastic materials. Monty Rakusen/Cultura/Getty Images Exposure to oxides of nitrogen. is believed to be the earliest change that occurs in the lung in cigarette smokers. when welding in enclosed spaces such as boilers. and the lesion is an acute bronchiolitis. when the victim develops a short cough and progressive shortness of breath. Symptomatic recovery may mask incomplete resolution of the inflammation. but a short cough and progressive shortness of breath may not be evident for hours. which may occur from inhaling gas in silos. These develop some hours later. after blasting underground. A chest radiograph shows patchy inflammatory change.7 Infectious Diseases of the Respiratory System 7 Welding in enclosed spaces often results in exposure to oxides of nitrogen. 101 . An inflammation around the small airways. known as a respiratory bronchiolitis.

The flu may affect individuals of all ages. bronchial tubes. The inflammation is probably reversible if smoking is discontinued. after which the onset of symptoms is abrupt. 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. by such means as inhalation of infected droplets resulting from coughing and sneezing. A diffuse headache and severe muscular aches throughout the body are experienced.7 The Respiratory System 7 although it does not lead to symptoms of disease at that stage. chills. and it is generally more frequent during the colder months of the year. Influenza Influenza. Symptoms associated with respiratory tract 102 . with sudden and distinct chills. also known simply as the flu (or grippe). The temperature rises rapidly to 38–40 °C (101–104 °F). The incubation period of the disease is one to two days. and a generalized feeling of weakness and pain in the muscles. and the person begins to recover. In three to four days the temperature begins to fall. and trachea. is an acute viral infection of the upper or lower respiratory tract that is marked by fever. often accompanied by irritation or a sense of rawness in the throat. together with varying degrees of soreness in the head and abdomen. though the highest incidence of the disease is among children and young adults. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. fatigue. and muscle aches. Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. As the virus particles gain entrance to the body.

Protection from one vaccination seldom lasts more than a year. ingestion of fluids. routine immunization in healthy people is also recommended.7 Infectious Diseases of the Respiratory System 7 infection. It is recommended that children and teenagers with the flu not be given aspirin. as treatment of viral infections with aspirin is associated with Reye syndrome. Other than this. a very serious illness. become more prominent and may be accompanied by lingering feelings of weakness. as well as a strain of virus known as influenza type B. these drugs inhibit influenza A. was introduced in the late 1990s. usually among older people already weakened by other debilitating disorders. and the use of analgesics to control fever. However. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. the neuraminidase inhibitors. However. Treatment and Prevention The antiviral drugs amantadine and rimantadine have beneficial effects on cases of influenza involving a strain of virus known as influenza type A. and is caused in most of those cases by complications such as pneumonia or bronchitis. viral resistance to these agents has been observed. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. Death may occur. and yearly vaccination may be recommended. thereby reducing their effectiveness. A newer category of drugs. These viruses are produced in chick embryos and rendered noninfective. the standard treatment remains bed rest. In order to prevent humaninfecting bird flu viruses from mutating into more 103 . such as coughing and nasal discharge.

There is evidence that the most common subtype of influenza type A virus. Through the inhibition of neuraminidase. If taken within 30 hours of 104 . Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. increases the formation of viral aggregates.S. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. increases the formation of viral aggregates. zanamivir decreases the release of virus from infected cells. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. 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. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. Inc. has developed resistance to oseltamivir.based pharmaceutical company Hoffman–La Roche. and decreases the spread of the virus through the body. Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. known as H1N1. and decreases the spread of the virus through the body. Zanamivir is given by inhalation only. Oseltamivir is marketed as Tamiflu by the U.7 The Respiratory System 7 dangerous subtypes. Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. Oseltamivir is effective when administered within two days of symptom onset. a glycoprotein on the surface of influenza viruses. the drug decreases the release of virus from infected cells.S. Oseltamivir can be given orally.

zanamivir can shorten the duration of the illness. or “whoop. the causative agent of whooping cough.” The coughing ends with the expulsion of clear. Zanamivir. Bordetella pertussis. Centers for Disease Control and Prevention (CDC) (Image Number: 2121) 105 . can prevent influenza infection in some adults and children. isolated and coloured with Gram stain. or pertussis. sticky mucus and often with vomiting. is an acute. when taken once daily for 10 to 28 days.7 Infectious Diseases of the Respiratory System 7 the onset of influenza. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. highly communicable respiratory disease. Whooping cough is caused by the bacterium Bordatella pertussis. Whooping Cough Whooping cough.

In the paroxysmal state. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. and pertussis) vaccine. the illness progresses through three stages—catarrhal. and occasionally convulsions and indications of brain damage. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. The infected person may appear blue. red eyes. variable in duration but commonly lasting four to six weeks. Beginning its onset after an incubation period of approximately one week. but the periods between coughing paroxysms are comfortable. The disease was first adequately described in 1578. Whooping cough is worldwide in distribution and among the most acute infections of children. and a low-grade fever. In 1906 at the Pasteur Institute. During the convalescent stage there is gradual recovery. undoubtedly it had existed for a long time before that. there is a repetitive series of coughs that are exhausting and often result in vomiting. paroxysmal. It was first called the Bordet-Gengou bacillus. ear infections. it confers active immunity against whooping cough to children. the name pertussis (Latin: “intensive cough”) was introduced in England. with bulging eyes. tetanus. and still later Bordetella pertussis. Catarrhal symptoms are those of a cold. Immunization is routinely begun at two months of age and requires five shots for maximum 106 . Now included in the DPT (diphtheria. Complications of whooping cough include pneumonia. with a short dry cough that is worse at night. and convalescent—which together last six to eight weeks. slowed or stopped breathing. later Haemophilus pertussis.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. and be dazed and apathetic. About 100 years later.

also known as ornithosis (or parrot fever). ducks. Strict regulations followed concerning 107 . Later vaccinations are in any case thought to be unnecessary. and another booster is given when the child is between four and six years old. Sedatives may be administered to induce rest and sleep. Psittacosis Psittacosis. During the investigations conducted in Germany. and the United States. The association between the human disease and sick parrots was first recognized in Europe in 1879. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. when severe outbreaks. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. and geese are the principal sources of human infection. the causative agent was revealed. attributed to contact with imported parrots. occurred in 12 countries of Europe and America. from which the disease is named). Treatment includes erythromycin. parrots and parakeets (family Psittacidae. and sometimes the use of an oxygen tent is required to ease breathing. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. pigeons. because the disease is much less severe when it occurs in older children. although a thorough study of the disease was not made until 1929– 30. an antibiotic that may help to shorten the duration of illness and the period of communicability. England. turkeys.7 Infectious Diseases of the Respiratory System 7 protection. especially if they have been vaccinated in infancy. The infection has been found in about 70 different species of birds.

viruses more commonly play a part in weakening the lung. but penicillin and the tetracycline drugs reduced this figure almost to zero. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. Other symptoms include chills. in particular species of Streptococcus and Mycoplasma. In humans psittacosis may cause high fever and pneumonia. because of impaired immunity. The typical duration of the disease is two to three weeks. Many organisms. and convalescence often is protracted. and an elevated respiratory rate. Although viral pneumonia does occur. Before modern antibiotic drugs were available. inhalation of foreign particles. thus inviting secondary pneumonia caused by bacteria. but the most common causes are bacteria. but it usually occurs in hospitalized persons who. Psittacosis usually causes only mild symptoms of illness in birds. Infected turkeys. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. can cause pneumonia. or geese have caused many cases among poultry handlers or workers in processing plants. weakness. or irradiation. ducks. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. but in humans it can be fatal if untreated. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. Pneumonia Pneumonia is an inflammation and solidification of the lung tissue as a result of infection.7 The Respiratory System 7 importation of psittacine birds. have reduced resistance to 108 . Fungal pneumonia can develop very rapidly and may be fatal. including viruses and fungi. head and body aches. the case fatality rate was approximately 20 percent.

caused by Streptococcus pneumoniae. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing.7 Infectious Diseases of the Respiratory System 7 infection. smoke inhalation).. Sputum discharge may contain flecks of blood. Contaminated dusts. the illness may become very severe. or allergic response. cough. and recovery generally occurs in a few weeks. can sometimes cause fungal lung diseases. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the 109 . The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. and difficulty in breathing. coughing becomes the major symptom. These fluids provide an environment in which the bacteria flourish. to agents such as mold. Bacterial Pneumonia Streptococcal pneumonia. is the single most common form of pneumonia.g. particularly in elderly people and young children. Pneumonia can also occur as a hypersensitivity. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract. however. humidifiers. Treatment is with specific antibiotics and supportive care. As the disease progresses. especially in hospitalized patients. In some cases. chest pain. and animal excreta or to chemical or physical injury (e. when inhaled by previously healthy individuals. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. and it is sometimes fatal. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills.

it does not invade the deeper tissues—muscle fibres. Most outbreaks of this disease are confined to families. an atypical infectious form. Mycoplasmal pneumonia. Other bacterial pneumonias include Legionnaire disease. M. usually affects children and young adults. but it does sometimes inflame the bronchi and alveoli. small neighbourhoods. an extremely small organism. Symptoms of 110 . Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. Research into the development of aerosol agents that stimulate blood clotting and that can be inhaled into the lungs and possibly be used in conjunction with traditional therapies for streptococcal pneumonia is ongoing. and influenza viruses. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. although epidemics can occur. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. causing bleeding into the air spaces. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. caused by Mycoplasma pneumoniae. caused by Legionella pneumophilia. and psittacosis. although it has little ability to infect the lungs of healthy persons. Another bacterium. elastic fibres. or institutions. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. few cases beyond age 50 are seen. Usually the organism does not invade the membrane that surrounds the lungs.7 The Respiratory System 7 lungs. parainfluenza. or nerves. Klebsiella pneumoniae. which leads to the further release of pneumolysin.

old sheds or barns. room humidifiers. and air-conditioning ducts. and low-grade fever. Initially. decreased appetite. the prognosis is excellent. AIDS. Nonbacterial pneumonia is treated primarily with supportive care. In general. and malaise. cough. In addition. usually followed by respiratory congestion and cough. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. A more insidious form of hypersensitivity pneumonia is 111 . all of which may subside in a day if there is no further exposure. Tuberculosis should always be considered a possibility in any patient with pneumonia. Diagnosis is established by physical examination and chest X-rays. pigeons. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. these patients experience fever with chills.7 Infectious Diseases of the Respiratory System 7 these pneumonias include runny nose. headache. or dust storms. all of which contain the fungus Actinomyces. backyard swimming pools. These pneumonias may occur following exposure to moldy hay or sugarcane. parakeets. and doves may develop manifestations of hypersensitivity pneumonia. Other fungi found in barley. or other chronic diseases. and wood pulp may cause similar illnesses. particularly if the patient was recently exposed to excavations. gerbils. maple logs. muscle pain. and skin testing is included in the initial examination of patients with lung problems. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. shortness of breath. people exposed to rats.

The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. Diagnosis is established by medical history. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. This type of disease. bed rest. Oil that is being swallowed may be breathed into the respiratory tract. known as lipoid pneumonia. and supportive care. Scar tissue forms as a result of the presence of the oil. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. it had been known that if the immune system was compromised by immunosuppressive drugs (given. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. before organ transplantation to reduce the rate of rejection). capable of causing invasive pneumonic lesions in the setting of reduced immunity. and may prove fatal. are difficult to treat. less often. weight loss. and specific laboratory tests.7 The Respiratory System 7 associated with persistent malaise. or. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. Pneumonia in Immunocompromised Persons For some years prior to 1980. Treatment consists of removing the patient from the offending environment. physical examination. it may come from the body itself when the lung is physically injured.) Recovery is usual unless too great an area of lung tissue is involved. fever. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. and cough. for example. Such infections are a major cause of illness in these patients. Infections with fungi such as 112 . Ordinarily no treatment is necessary. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue.

Although it is fairly well documented that the disease is rarely spread through person-to-person contact. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. confirmed in more than 300 people. Potable water and drainage systems are suspect.7 Infectious Diseases of the Respiratory System 7 Candida also occur. at a Philadelphia hotel where 182 Legionnaires contracted the disease. The largest known outbreak of Legionnaire disease. 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. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. a U. followed by high fever. Although healthy individuals can contract Legionnaire disease. the first symptoms of Legionnaire disease are general malaise and headache. Coughing. military veterans’ organization. and abdominal distress are common. 113 . Legionnaire Disease Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. and occasionally some mental confusion is present. pleurisy-like pain. shortness of breath. pneumophila in droplets into the surrounding atmosphere. occurred in Murcia. Typically. Spain. 29 of them fatally. but not uniformly. often accompanied by chills.S. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. as is water at construction sites. in 2001. the exact source of outbreaks is often difficult to determine.

at which time improved health and hygiene brought about a steady decline in its mortality rates. In some cases. L. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication. represents a milder form of Legionella infection. “consumption. Mycobacterium tuberculosis. headache. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. an influenza-like illness characterized by fever. pneumophila enters the lungs. L. Tuberculosis Tuberculosis is an infectious disease that is caused by the tubercle bacillus. Blood vessels also can be eroded by the advancing disease. Since the 114 . causing the infected person to cough up bright red blood. the macrophage dies and bursts open. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. In most forms of the disease. this cycle of infection can lead to severe pneumonia. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. and muscle pain. However. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. pneumophila. Indeed. During the 18th and 19th centuries. coma. Pontiac fever.7 The Respiratory System 7 Once in the body. Eventually. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. the bacillus spreads slowly and widely in the lungs.” as it was then known. and death. Treatment for Legionnaire disease is with antibiotics.

the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 . tuberculosis remains a major fatal disease. In addition. and drug therapy has done away with the old TB sanatoriums where patients at one time were nursed for years while the defensive properties of their bodies dealt with the disease. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. Fox Photos/Hulton Archive/Getty Images 1940s. but in areas with poor hygiene standards. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. antibiotic drugs have reduced the span of treatment to months instead of years. it continues to be a fatal disease continually complicated by drug-resistant strains.7 Infectious Diseases of the Respiratory System 7 Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries. Today. in less-developed countries where population is dense and hygienic standards poor.

coughing. In this condition. but most of the visible manifestations of tuberculosis. sometimes called latent 116 . nodular tubercles. The Course of Tuberculosis The tubercle bacillus is a small. rod-shaped bacterium that is extremely hardy. it can survive for months in a state of dryness and can also resist the action of mild disinfectants. and the infected person acquires a lifelong immunity to the disease. sometimes involving the use of five different agents. the primary infection often heals without causing symptoms. cheeselike (caseous) in appearance. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. from barely visible nodules to large tuberculous masses. Infections with these strains are often difficult to treat and require the use of combination drug therapies. There the bacilli become trapped in the tissues of the body. and a small scar in the lung may be visible by X-ray.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. and finally are sealed up in hard. are conglomerations of tubercles. in which can be found many bacilli. are surrounded by immune cells. A tubercle usually consists of a centre of dead cells and tissues. Minute droplets ejected by sneezing. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. A skin test taken at any later time may reveal the earlier infection and the immunity. Individual tubercles are microscopic in size. The bacilli are quickly sequestered in the tissues. In otherwise healthy children and adults. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person.

an alarming symptom. and there may be blood in the sputum. Eventually. the elderly. this disease was always fatal. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. From the blood the bacilli create new tissue infections elsewhere in the body. once the bacilli enter the bloodstream. Particularly among infants. In the lung. An infection of the meninges that cover the brain causes tuberculous meningitis. These symptoms do not subside. skin. the cough increases. causing a pleural effusion. they can travel to almost any organ of the body. the affected person is not contagious. however.7 Infectious Diseases of the Respiratory System 7 tuberculosis. and the general health of the patient deteriorates. a highly fatal form if not adequately treated. the original tubercles break down. weight loss. In some cases. usually with drenching night sweats. genital organs. bones and joints. This lesion may erode a neighbouring bronchus or blood vessel. releasing viable bacilli into the bloodstream. the primary infection may spread through the body. and bladder. Tubercular lesions 117 . and persistent cough. kidneys. The onset of pulmonary tuberculosis is usually insidious. or collection of fluid outside the lung. the patient may have chest pain from pleurisy. and immunocompromised adults (organ transplant recipients or AIDS patients. with lack of energy. including the lymph nodes. a highly infectious stage of the disease. This causes a condition known as pulmonary tuberculosis. Fever develops. causing the patient to cough up blood (hemoptysis). sometimes after periods of time that can reach 40 years or more. In fact. most commonly in the upper portion of one or both lungs. intestines. before the advent of specific drugs. though most affected people now recover. In some cases the infection may break into the pleural space between the lung and the chest wall. for example). causing miliary tuberculosis.

M. aviumintracellulare). The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. M. and M. M. and this. If the milk is ingested raw. and it is also excreted in milk. where it causes destruction of tissue and eventually gross deformity. kansasii. bovis readily infects humans. or Pott disease. The amount of lung tissue available for the exchange of gases in respiration decreases. is the cause of bovine tuberculosis. where it causes caseation of the node tissue (a condition formerly known as scrofula). Pasteurization of milk kills tubercle bacilli. however. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. a great preference for bones and joints. atypical mycobacteria. has led to the disappearance of bovine tuberculosis in humans in many countries. finally eroding through the skin as a chronic discharging ulcer. cavities. and scarring. 118 . M. Tuberculosis of the spine. often resulting in a hunchback deformity. causing large areas of destruction. bovis is transmitted among cattle and some wild animals through the respiratory route. The node swells under the skin of the neck. It shows. and mycobacteria other than tuberculosis (MOTT). M. Other Mycobacterial Infections Another species of bacteria. bovis. bovis may spread into the bloodstream and reach any part of the body. marinum. This group includes such Mycobacterium species as M. M. ulcerans. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. From the gastrointestinal tract. avium (or M.7 The Respiratory System 7 may spread extensively in the lung. is characterized by softening and collapse of the vertebrae. along with the systematic identification and destruction of infected cattle.

It has been widely used in some countries with success. but they cause dangerous illnesses of the lungs. it causes a local reaction. tuberculosis. is composed of specially weakened tubercle bacilli. in which a sputum specimen is smeared onto a slide. Treatment is attempted with various drugs. which confers some immunity to infection by M. Among AIDS patients. lies in preventing exposure to infection. An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. In many developed countries. stained with a compound that penetrates the organism’s cell wall. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. individuals at risk 119 .7 Infectious Diseases of the Respiratory System 7 These bacilli have long been known to infect animals and humans. however. in the urine. known as BCG vaccine. and other organs only in people whose immune systems have been weakened. The main hope of ultimate control. and this means treating infectious patients quickly. A vaccine. possibly in isolation until they are noninfectious. The primary method used to confirm the presence of bacilli is a sputum smear. If bacilli are present. and examined under a microscope. in gastric washings. atypical mycobacterial illnesses are common complications of HIV infection. or in the cerebrospinal fluid. lymph nodes. Injected into the skin. but the prognosis is usually poor owing to the AIDS patient’s overall condition. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. tuberculosis for several years. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. its use in young children in particular has helped to control infection in the developing world.

the surviving bacilli will become resistant to several drugs. making the patient sick again. The patient is usually made noninfectious quite quickly. of bed rest and surgical removal of useless lung tissue. These drugs are often used in various combinations with other agents. These drugs may be given daily or two times per week. rifampicin. such as health care workers.7 The Respiratory System 7 for tuberculosis. or rifapentine. treatment of tuberculosis consisted of long periods. 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. often years. As a result. pyrazinamide. with early drug treatment. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. surgery is rarely needed. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. in order to avoid the development of drug-resistant bacilli. 120 . If a patient does not continue treatment for the required time or is treated with only one drug. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. If subsequent treatment is also incomplete. Historically. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. and pyrazinamide. Today. bacilli will become resistant and multiply. but complete cure requires continuous treatment for another four to nine months. ethambutol.

Aggressive treatment using five different drugs. Although some patients consider DOT invasive. in part to prevent the development and spread of MDR TB. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). Instead of taking daily medication on their own. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient.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. 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. MDR TB is treatable but is extremely difficult to cure. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. In 1995. such as kanamycin. amikacin. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. In addition. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. 121 . typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. or capreomycin. it has proved successful in controlling tuberculosis.

bronchial tree. and lungs. The causes of the various diseases and disorders are diverse. It is common for more than one part of the system to be involved in any particular disease process. Thus. Although these divisions provide a general outline of the ways in which diseases may affect the lung. emphysema. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. diseases of the larynx. Treatment for this group of conditions is similarly varied. palate. and in many cases therapy may include not only the administration of medications but invasive surgery as well. ranging from inherited genetic mutations to smoking to trauma. sinuses. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect. and nasopharynx are all susceptible to disease. Important examples of diseases and disorders of the respiratory system include sleep apnea. there are diseases of the upper airways. and cystic fibrosis.CHAPTER5 DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. and diseases of the mediastinum and diaphragm. T diseases of the upper airway The nose. and disease in one region frequently leads to involvement of other parts. Conditions affecting these tissues may 122 . trachea. they are by no means rigid. diseases of the pleura.

hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords. Snoring is more common in the elderly because the loss of tone in the oropharyngeal Although snoring bears the brunt of many jokes. Snoring Snoring is a rough. cancer). loud interrupted snoring can indicate sleep apnea. such as congenital structural abnormalities or malignant neoplastic changes (i. © www . which necessitates breathing through the mouth. a potentially life-threatening condition.e. Such cancers are typically more common in smokers than in nonsmokers..istockphoto. It is often associated with obstruction of the nasal passages.7 Diseases and Disorders of the Respiratory System 7 result from a number of different / Stephanie Horrocks 123 .

The word apnea is derived from the Greek apnoia.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx. and mixed. meaning “without breath. and it occurs most often in obese persons. the condition has a strong association with certain measures of obesity. Whatever the cause. which is the most common form and involves the collapse of tissues of the upper airway. In obstructive sleep apnea (OSA). at which point the airway reopens and the person resumes breathing. which involves characteristics of both obstructive and central apneas.” There are three types of sleep apnea: obstructive. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. Loud interrupted snoring is a regular feature of sleep apnea. such as neck size. or body-mass index. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. In men shirt size is a useful predictor. body weight. airway collapse is eventually terminated by a brief awakening. It is also more common in men than in women. Children’s snoring usually results from enlarged tonsils or adenoids. a common and potentially lifethreatening condition that generally requires treatment. Obstructive sleep apnea is most often caused by excessive fat in the neck area. Thus. central. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. In addition. snoring is always associated with mouth breathing and can be corrected by removing obstructions to normal nasal breathing or by altering sleeping position so that the affected individual does not lie on his back. with the likelihood of OSA increasing 124 .

7 Diseases and Disorders of the Respiratory System 7 with a collar greater than about 42 cm (16. Although CPAP does not treat the condition itself. such as hypothyroidism or tonsillar enlargement. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. which can be resolved only by weight loss or treatment of underlying conditions. Treatment typically involves continuous positive airway pressure (CPAP). it is less certain that these diseases are caused by OSA.and sevenfold. the magnitude of the increased risk is the subject of some debate but is thought to be between three. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. The most common symptom of OSA is sleepiness. hypertension. 125 . The risk returns to normal after treatment. The condition is also more common in patients with a set-back chin (retrognathia). which uses a mask (facial or nasal) during sleep to blow air into the upper airway. it does prevent airway collapse and thus relieves daytime sleepiness. Other causes of the condition include medical disorders. worsen short-term memory. including ischemic heart disease. Sleep disturbance may cause difficulty concentrating. and insulin resistance. with many patients describing sleep as unrefreshing. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. though surgery is seldom recommended. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. However. and increase irritability. with the resumption of breathing usually described as a gasp or a snort.5 inches).

who showed some of the same traits. in the space known as the pleural cavity. The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level. drowsiness. Individuals who have pickwickian syndrome often complain of slow thinking. Low blood oxygen causes the small blood vessels entering the lungs to constrict. leading to respiratory acidosis. The elevated pressure stresses the right ventricle of the heart. Finally. Because of inadequate removal of carbon dioxide by the lungs. and fatigue. especially beneath the skin of the lower legs.) This condition often occurs in association with sleep apnea. to be obese is to exceed one’s ideal weight by 20 percent or more. diseases of the pleura The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. levels of carbon dioxide in the blood increase. is a complex of respiratory and circulatory symptoms associated with extreme obesity. thus increasing pressure in the vessels that supply the lungs. (By some definitions. The pleural membranes of the 126 . In more severe instances. excessive fluid accumulates throughout the body (peripheral edema).7 The Respiratory System 7 Pickwickian Syndrome Pickwickian syndrome. oxygen in the blood is also significantly reduced. ultimately causing right heart failure. an extremely obese person would exceed the optimum weight by a much larger percentage. also known as obesity hypoventilation syndrome. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers.

This causes spontaneous pneumothorax. is an inflammation of the pleura. little or no abnormal fluid accumulates in the pleural cavity. In wet pleurisy. the membranes that line the thoracic cavity and fold in to cover the lungs. a partial or occasionally complete collapse of the lung. or hydrothorax. Pleural Effusion and Thoracic Empyema Pleural effusion. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. including tissues of the neck and head. a cancer of the pleura. may occur many years after inhalation of asbestos fibres. Pleurisy is commonly caused by infection in the underlying lung and.7 Diseases and Disorders of the Respiratory System 7 lungs are also vulnerable to perforation and spontaneous rupture. pleurisy can be very painful. and treatment of the underlying disease. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. Treatment of pleurisy includes pain relief. Mesothelioma. fluid evacuation. Pleurisy Pleurisy. rarely. enabling air to enter the pleural cavity. also called pleuritis. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. fluids produced by the inflamed tissues accumulate within the pleural cavity. Because the pleura is well supplied with nerves. by diffuse inflammatory conditions such as lupus erythematosus. There are many causes of 127 . This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. In dry pleurisy. is an accumulation of watery fluid in the pleural cavity. Pleurisy may be characterized as dry or wet.

thereby preventing the accumulation of more fluid. and the spread of a malignant tumour from a distant site to the pleural surface. Treatment is directed at drainage of small amounts of pus through 128 . and bleomycin. tuberculosis. and fluid that seeps from the lungs places additional stress on the dysfunctioning heart. infection within the pleural cavity. Large pleural effusions can cause disabling shortness of breath. tissue adhesions obliterate the pleural space. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. The accumulation of pus in the pleural cavity is known as thoracic empyema.e. and weight loss. As the inflammation heals.. including pneumonia. doxycycline. This condition is often the result of a microbial. a tube is inserted through the chest wall into the pleural space to drain the fluid. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. air may get into the pleural cavity. usually bacterial. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. 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. shortness of breath. If symptoms of pleural effusion develop. Thoracic empyema may be characterized by fever. such as malignant disease of the pleura (i. The presence of both air and pus inside the pleural cavity is known as pneumothorax. When the bronchial tree is involved in the infection.7 The Respiratory System 7 pleural effusion. or pyothorax. mesothelioma). It may also be caused by a lung abscess or some forms of tuberculosis. and the presence of fluid as ascertained by a chest X-ray. Under certain conditions. coughing.

The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. 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. or thoracoscopy (closed-lung biopsy). Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. gunshot) or other injuries to the chest wall. Pneumothorax Pneumothorax is a condition in which air accumulates in the pleural space. chest compression during cardiopulmonary resuscitation (CPR). in tension pneumothorax air that becomes trapped in the pleural space cannot escape. In contrast to traumatic pneumothorax and spontaneous pneumothorax. the heart. causing it to expand and thus compress the underlying lung. with each breath the patient inhales. lung infection.7 Diseases and Disorders of the Respiratory System 7 a needle or larger amounts through a drainage tube. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. and tension pneumothorax. such as high-pressure mechanical ventilation. which may then collapse. blood 129 . When the lung on the affected side of the chest collapses. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. There are three major types of pneumothorax: traumatic pneumothorax. air and pressure accumulate within the chest. after which air is sucked through the opening and into the pleural sac. As a result. or medical procedures. spontaneous pneumothorax. Antibiotics are used to treat the underlying infection.

7 The Respiratory System 7 vessels. thereby compressing the other lung. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. Most pneumothoraxes can be treated by inserting a tube through the chest wall. The bronchi become chronically infected. including bronchiectasis and cystic fibrosis. which enables the lung to reexpand. a catheter connected to a vacuum system is required to re-expand the lung. and excess sputum production and episodes of chest infection are common. clubbing (swelling of the fingertips and. It consists of a dilatation of major bronchi. In some cases. In some cases. In fact. occasionally. possibly after a severe attack of pneumonia. may be present in childhood. The disease may also develop as a consequence of airway obstruction or of undetected (and 130 . many of these conditions are associated with irreversible lung damage. and airways are pushed to the centre of the chest. This procedure allows air to escape from the chest cavity. others may require surgery to prevent recurrences. Whereas several diseases of the bronchi and lungs. This leads to decreases in blood pressure. and breathing that in turn may lead to shock and death. of the toes) may occur. Bronchiectasis Bronchiectasis is believed to usually begin in childhood. While small pneumothoraxes may resolve spontaneously. consciousness. diseases of the bronchi and lungs Diseases of the bronchi and lungs are often associated with significant impairments in respiration.

now reach adult life. After about 15 years of smoking. 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. many of whom. such as parts of plastic toys. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants. medications to dilate the airways and to relieve pain. Bronchiectasis may also develop as a consequence of inherited conditions. The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air. or of organic substances such as hay dust. particularly in areas of uncontrolled coal burning.” without serious implications. significant quantities of mucus are coughed up in the morning. due to an increase in size and number of mucous glands lining the large airways. In some countries chronic bronchitis is caused by daily 131 . of which the most important is the familial disease cystic fibrosis.7 Diseases and Disorders of the Respiratory System 7 therefore untreated) aspiration into the airway of small foreign bodies. enzyme therapy to thin the mucus. 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. These therapies. in addition to others. have helped control pulmonary infections and have markedly improved survival in affected persons. Chronic Bronchitis The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough. Management of the condition includes antibiotics to fight lung infections. For example. who would formerly have died in childhood.

the coexistence of these two conditions is known as chronic obstructive pulmonary disease. By the time this occurs. consisting of expectorants and bronchodilators. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. though the rate of progression generally slows. Because the damage to the bronchial tree is largely irreversible. whereas others may experience severe respiratory compromise after 15 years or less of exposure. in a cigarette smoker.7 The Respiratory System 7 inhalation of wood smoke from improperly ventilated cooking stoves. Smoking-related chronic bronchitis often occurs in association with emphysema. All these changes together. but they must be used sparingly because they can be addictive and because expectoration is necessary. Unfortunately. is severely compromised. drugs to suppress paroxysmal coughing may be necessary. Some people can smoke for decades without evidence of significant airway changes. Of primary importance is 132 . can lead to disturbances in the distribution of ventilation and perfusion in the lung. Occasionally. The mucus-producing cough will subside within weeks or months and may resolve altogether. if severe enough. the ventilatory ability of the patient. though these produce the dominant symptom of chronic sputum production. treatment is mainly symptomatic. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. ventilatory ability has usually been declining rapidly for some years. For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. The changes are not confined to large airways. It is not clear what determines the severity of these changes. as measured by the velocity of a single forced expiration. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension.

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.

Pulmonary Emphysema
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

In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. antibiotics. Exacerbations are triggered by infection. and each year about 30. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation).000 people in the United Kingdom and roughly 119. Sources of noxious particles that can cause COPD include tobacco smoke. which 137 . Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. which causes increased lung volume and manifests as breathlessness. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). air pollution. are not always required. and by a tendency for excessive mucus production in the airway. which work against bacteria. particularly if severe enough to warrant hospital admission. it is increasingly recognized that COPD has secondary associations.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. which is replaced by holes characteristic of emphysema. and the burning of certain fuels in poorly ventilated areas. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. Therefore. COPD is distinguished pathologically by the destruction of lung tissue. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production.000 people in the United States die from COPD. which gives rise to symptoms of bronchitis. Frequent exacerbations. Coughing up blood is not a feature of COPD and when present raises concern about a second. particularly lung cancer. tobacco-related condition. It is a common disease. indicate a poor prognosis. including muscle weakness and osteoporosis. Although primarily a lung disease. either bacterial or viral.

Inhaled corticosteroids are commonly prescribed. Some COPD patients do not find oxygen attractive. Active congestion of the lungs is caused by 138 . In addition.. including noninvasive ventilation and surgical options (i. In COPD patients with low blood–oxygen levels. lung transplantation and lung-volume reduction). inability of the heart to function adequately).7 The Respiratory System 7 can be accomplished in most cases by cessation of smoking. Specialized centres can offer treatments for patients with advanced eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy. which leads to further difficulties in mobility.e. bronchodilators). oxygen is extremely flammable. A six...e. since they need to use it for 16 hours each day to derive benefit. 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. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. This should be followed by a community/home maintenance program or by repeat courses every two years. high blood pressure. especially for patients with frequent exacerbations.e. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD. 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.

The major complication arises in mild cases of pneumonia. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue. The blood pressure becomes high in the alveolar capillaries. Passive congestion is due either to high blood pressure in the capillaries. caused by a cardiac disorder. and the precipitating causes may somewhat differ. 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. narrowing of the valve between the upper and lower chambers in the left side of the heart. although there is usually enough unaffected lung tissue for respiration. flooding them. rather than whole blood. when the remaining functioning tissue becomes infected. Blood accumulates in the lower part of the lungs.7 Diseases and Disorders of the Respiratory System 7 infective agents or irritating gases. causes chronic passive congestion. Eventually the pressure becomes too great. there is a bloody discharge. Mitral stenosis. liquids. and blood escapes through the capillary wall into the alveoli. The walls of the alveoli also thicken and gas exchange is greatly impaired. and the skin takes on a bluish tint as the disease progresses. The affected person shows difficulty in breathing. Inflammatory edema results from influenza or bacterial pneumonia. and they begin to distend. In 139 . and particles. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. or to relaxation of the blood capillaries followed by blood seepage. The alveolar walls and the capillaries in them become distended with blood.

Dr.7 The Respiratory System 7 X-ray showing lung congestion caused by congestive heart failure. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6241) 140 .

and obstructive. The term is derived from the Greek words atele s and ektasis. the person may actually drown in the lung secretions. their lungs show areas in which the alveoli. literally meaning “incomplete expansion” ¯ in reference to the lungs. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. The term atelectasis can also be used to describe the collapse of a previously inflated lung. if too great a volume of intravenous fluids is given. because of specific respiratory disorders. and heavy. enlarged. Adhesive atelectasis is seen in premature infants who are unable to spontaneously breathe and in some infants after only a few days of developing breathing difficulties. the blood pressure rises and edema ensues. are not expanded with air. After an operation. with deep gurgling rattles in the throat.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. because he or she is too weak to clear the fluids. Excessive irradiation and severe allergic reactions may also produce this disorder. for unknown reasons. wet. There are three major types of atelectasis: adhesive. These infants usually suffer from a disorder called respiratory distress syndrome. This is typically caused by a failure to develop surface-active material 141 . compressive. Acute cases can be fatal in 10 to 20 minutes. The person’s skin turns blue. or air sacs. and. The lungs become pale. It can occur. It may take only one or two hours for two to three quarts of liquid to accumulate. after reinflation of a collapsed lung. either partially or fully. A person with pulmonary edema experiences difficulty in breathing. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed.

Dr.7 The Respiratory System 7 X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242) 142 .

soot. The symptoms in extreme atelectasis include low blood oxygen content. and consolidation of the lungs into a smaller mass. and bacterial cells. or elevation of the diaphragm. absence of respiratory movement on the side involved. they can be pushed out of the bronchi by coughing or strong exhalation of air. Treatment for infants with this syndrome includes replacement therapy with surfactant. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out. and respiratory function cannot be restored. the anesthetic stimulates an increase in bronchial secretions. If a lung remains collapsed for a long period. an enlarged heart. It may also occur as a complication of abdominal surgery. which frequently enter with inhaled air. and the muscles beneath the lungs may be weakened. Mucous plugs can result that cause atelectasis. Treatment for obstructive and compressive 143 . displacement of the heart toward the affected side. Other causes of obstruction include tumours or infection. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements. which manifests as a bluish tint to the skin. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. Generally. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. Local pressure can result from tumour growths. The air passageways in the lungs normally secrete a mucous substance to trap dust.7 Diseases and Disorders of the Respiratory System 7 (surfactant) in the lungs. if these secretions become too abundant. the respiratory tissue is replaced by fibrous scar tissue. After abdominal surgery. causing air trapped in the alveoli to be slowly absorbed by the blood. When a person undergoes surgery. Collapse is complete if the force is uniform or is partial when the force is localized.

If the lung is congested. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. 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 section of dead tissue is called an infarct. infected. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. however. The pain may be localized around the rib cage. The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs.7 The Respiratory System 7 atelectasis is directed toward removal of any obstruction or compressive forces. infarcts that occur deep inside the lungs produce no pain. Lung Infarction Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. when the lungs are healthy. lung infarctions can follow blockage of a blood vessel. near the muscular diaphragm that separates the chest cavity from the abdomen. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. When pain is present it indicates pleural involvement. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac. such blockages fail to cause death of tissue because the blood finds its way by alternative routes. Ordinarily. Pain is most severe on inhalation. shoulders. and neck. or inadequately supplied with air. 144 . or it may be lower.

diminished breath sounds. those individuals who have one normal copy and one defective copy of the particular gene involved). sticky mucus that clogs the respiratory tract and the gastrointestinal tract. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures.e. It is much less common among people of African ancestry (about 1 per 17. by the mid-1980s. moderate difficulty in breathing. However. However. is an inherited metabolic disorder. The dead tissue is replaced by scar tissue.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. the chief symptom of which is the production of a thick. 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. The disorder was long known to be recessive (i. also known as mucoviscidosis..e. and a dull sound heard when the chest is tapped. only persons inheriting a defective gene from both parents will manifest the disease). pleural rubbing. increased heartbeat..000 live births in these populations and is particularly concentrated in people of northwestern European descent.000 live births) and is very rare in people of Asian ancestry. when both 145 . The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). The disease has no manifestations in heterozygotes (i. coughing. It is estimated to occur in 1 per 2. Cystic Fibrosis Cystic fibrosis. fever. Infarcts that do not heal within two or three days generally take two to three weeks to heal.

called cystic fibrosis transmembrane conductance regulator. The gene. on the basis of chance. Chronic cough. As a result. In 1989 the defective gene responsible for cystic fibrosis was isolated. chloride and sodium ions accumulate within cells. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. Bulky.7 The Respiratory System 7 parents are heterozygous. lies in the middle of chromosome 7 and encodes a protein of the same name. This results in chronic respiratory infections. Within the cells of the lungs and gut. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces.. plugging the bronchi and making breathing difficult. Most cases of cystic fibrosis are caused by a mutation that corresponds to the production of a CFTR protein that lacks the amino acid phenylalanine. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. or CFTR. one out of four of their offspring will have the disease. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. designated CFTR. foul-smelling stools are often the first signs of cystic fibrosis. The thick. greasy. often with Staphylococcus aureus or Pseudomonas aeruginosa. About 10 146 . the CFTR protein transports chloride across cell membranes and regulates other channels. and the progressive loss of lung function are the major manifestations of lung disease. the mucus-secreting and sweat glands) in the respiratory and digestive systems. recurrent pneumonia. sticky mucus accumulates in the lungs. In the digestive system. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet.g. they may expect that. which is the most common cause of death of persons with cystic fibrosis.

sometimes in aerosolized form. in order to fight lung infections. These tests are effective in the identification of adult carriers (heterozygotes). bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. which is powered by a compressor that sprays aerosolized drug into the airways. lung transplantation may be considered. protein. Medications such as dornase alfa. In severe cases. In addition. are given to thin mucus. who may pass a mutation on to their offspring. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. In addition. 147 . and fat. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. facilitating its clearance from the lungs through coughing. as well as in the identification of newborns who may be at risk for the disorder. making it easier for patients to breathe. The high salt content in perspiration is the basis for the “sweat test. Mutations associated with cystic fibrosis can be detected in screening tests. These agents may be administered by means of an inhaler or a nebulizer. a recombinant form of the enzyme deoxyribonuclease. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. Many patients with cystic fibrosis regularly take antibiotics. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content.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.” which is the definitive diagnostic test for the presence of cystic fibrosis.

and the outcomes of clinical trials are marked by steady improvement. Since the 1990s. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene. Gene therapy first emerged as a potential form of treatment in 1990. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. since increased expression of the CFTR protein was observed shortly after treatment. However. As a result. Delivery systems under investigation include cationic polymer vectors. including lung inflammation and signs of viral infection. These vectors were then transfected into the cultured cells. The latter. This first trial initially appeared to be successful. gene therapy for cystic fibrosis has undergone significant refinement. 148 . the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. and adenovirus associated virus. 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.7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. 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. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. cationic liposomes. However. the natural defense systems of the lungs and airways have proved significant obstacles to cellular uptake of the viral vector carrying the normal CFTR gene. the patients experienced severe side effects. has proved particularly effective in laboratory studies using human lung tissue.

Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. or granulomas. A dry cough is common as well.” are heard through a stethoscope applied to the back in the area of the lungs. Sharp crackling sounds. The disease most commonly manifests between ages 50 and 70. 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. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. the lung is commonly involved. The average duration of survival from diagnosis is four to six years. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. 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. In addition. Other common changes are enlargement of the lymph 149 . there is no effective treatment. however. with insidious onset of shortness of breath on exertion. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. Some individuals have clubbed fingertips and toes.7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. called rales or “Velcro crackles. in different organs. some people live 10 years or longer. Aside from administration of supplemental oxygen.

The disease usually remits without treatment within a year or so. Evidence of granulomas in the lung may be visible. The gas molecules must pass through a cellular wall. Eosinophilic granuloma. the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. Pulmonary Alveolar Proteinosis Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. and liver dysfunction. inflammation in the eye. skin changes.7 The Respiratory System 7 glands at the root of the lung. The alveoli are air sacs. a complex mixture of protein and lipid (fat) molecules.” leaving the lung with some permanent cystic changes. is a disease associated with the excess production of histiocytes. but often there is little interference with lung function. a subgroup of immune cells. or when the lung fails to remove the 150 . leading finally to lung fibrosis and respiratory failure. the incidence is greatly increased in cigarette smokers. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. but in a small proportion of cases it progresses. nerve sheaths are inflamed. also known as histiocytosis X. It causes lesions in lung tissue and sometimes also in bone tissue. minute structures in the lungs in which the exchange of respiratory gases occurs. Although its cause is unknown. When too much surfactant is released from the alveolar cells. Occasionally. leading to signs of involvement in the affected area. The kidney is not commonly involved. but some changes in blood calcium levels occur in a small percentage of cases. Eosinophilic granuloma is a lung condition that may spontaneously “burn out. In most cases the disease is first detected on chest radiographs.

The precipitating cause of the disease is unknown. but its cause is not fully understood. Persons affected are usually between ages 20 and 50. The skin becomes tinged with blue in the most serious cases.7 Diseases and Disorders of the Respiratory System 7 surfactant. Treatment involves removal of the material by a rinsing out of the lungs (lavage). an acute inflammatory disease of the blood vessels believed to be of immunologic origin. The fluids drawn back out of the lungs have been found to have a high content of fat. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. Pulmonary hemorrhage also occurs as part of a condition 151 . The condition has been successfully treated by exchange blood transfusion. Wegener granulomatosis. it is sometimes fatal. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. if treated. is an important cause of pulmonary blood vessel inflammation. The disease can exist without causing symptoms for considerable periods. One lung at a time is rinsed with a saltwater solution introduced through the windpipe. and it is often accompanied by chest pain and a dry cough. There may also be general fatigue and weight loss. Sometimes the lesions totally clear up after one procedure. Immunologic Conditions of the Lung The lung is often affected by generalized diseases of the blood vessels. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. but rarely so. but subsequent treatments are often necessary. and spontaneous improvement has been known to occur. X-rays most frequently show evidence of excess fluids in the lungs.

resulting in an estimated 1. by the use of pulmonary function tests. lung cancer is the second leading cause of death from cancer globally.3 million deaths each year. In the 21st century. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. which is also believed to have an immunologic basis.7 The Respiratory System 7 known as pulmonary hemosiderosis. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. leading finally to respiratory failure. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. accurate diagnosis has been much improved by refinements in radiological methods. a slowly obliterative disease of small airways (bronchiolitis) occurs. however. and the lung parenchyma may be involved. These conditions have only recently been recognized and differentiated. lung cancer emerged as the leading cause of cancer deaths worldwide. 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. In women. The rapid increase in the worldwide prevalence of lung cancer was attributed mostly to the increased use of cigarettes following World War I. it has surpassed breast cancer. following breast cancer. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. More rarely. In the United States. In the early 20th century it was considered relatively rare. 152 . Pleural effusions may occur. Lung cancer was first described by doctors in the mid-19th century.

small-cell 153 . and workers exposed to halogenated ethers also have an increased incidence. unexplained weight loss. Types of Lung Cancer Once diagnosed. tar refiners. The most common symptoms include shortness of breath. chromium and nickel refiners. bloody sputum. between 80 and 90 percent of all cases are caused by smoking. Uranium and pitchblende miners.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. visible lumps. as do some workers in hydrocarbon-related processing. or bone pain may occur. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. According to the American Cancer Society. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. welders. Lung cancer is rarely caused directly by inherited mutations. In countries with a prolonged history of cigarette smoking. In cases where the cancer has spread beyond the lungs. a persistent cough or wheeze. Of the two basic forms. Other risk factors include exposure to radon gas and asbestos. Heavy smokers have a greater likelihood of developing the disease than do light smokers. such as coal processors. secondhand smoke accounts for an estimated 3. the tumour’s type and degree of invasiveness are determined. The risk is also greater for those who started smoking at a young age. jaundice. Tumours can begin anywhere in the lung. and susceptibility to lower respiratory infections. and roofers. chest pain.400 deaths from lung cancer in nonsmoking adults in the United States each year.

Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. It is characterized by cells that are small and round. Small-cell carcinoma (SCLC). Cancer cells may be detected in sputum. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. Tumours often originate in the smaller. or shaped like oat grains. This tumour is characterized by flat. adenocarcinoma. Diagnosis. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. SCLC is the most aggressive type of lung cancer. Cells of adenocarcinoma are cube. pleura. also called epidermoid carcinomas. About 10 percent of all lung cancers are large-cell carcinomas. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide.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. also called oat-cell carcinoma. Because it tends to spread quickly before symptoms become apparent. is rarely found in people who have never smoked. and they form structures that resemble glands and are sometimes hollow. 154 . scalelike cells. 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. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. and it often develops in the larger bronchi of the central portion of the lungs. the survival rate is very low. and Prevention Lung cancers are often discovered during examinations for other conditions.or column-shaped. Treatment. oval. and both lungs or metastasis to other organs. but it is the most common type of lung cancer in the United States. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. and large-cell carcinoma. peripheral bronchi.

and radiation. As with most cancers. Even when it is detected early. For example. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. Surgery involves the removal of a cancerous segment (segmentectomy). or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. computed tomography (CT) 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. Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . which can identify mutations that render some lung cancers susceptible to specific drugs. or the entire lung (pneumonectomy). Lung surgery is serious and can lead to complications such as pneumonia or bleeding.7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. chemotherapy. treatments for lung cancer include surgery. Noninvasive methods include X-rays. The choice of treatment depends on the patient’s general health. Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. and the type of cancer. lung cancer has a poorer prognosis than many other cancers. For this reason. a lobe of the lung (lobectomy). the five-year survival rate is about 50 percent. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. and magnetic resonance imaging (MRI). The type of treatment an individual patient receives may also be based on the results of genetic screening. the stage or extent of the disease. 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.

and other airborne carcinogens also lowers risk. Side effects include vomiting. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation.7 The Respiratory System 7 following surgery to destroy small amounts of cancerous tissue. noninvasive cysts of different kinds are also found in the mediastinum. The probability of developing lung cancer can be greatly reduced by avoiding smoking. diarrhea. asbestos. but these chemicals also attack normal cells to varying degrees. Enlargement of lymph glands in this region is common. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the 156 . causing side effects that are similar to radiation therapy. diseases of the MediastinuM and diaphragM The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. Smokers who quit also reduce their risk significantly. Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). Chemotherapy uses chemicals to destroy cancerous cells. which relies on heat derived from microwave energy to kill cancer cells. Testing for radon gas and avoiding exposure to coal products. fatigue. particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. or additional damage to the lungs. together with the many important structures situated within it.

and the trachea. If the diver breathes normally or exhales as he or she ascends at a moderate rate. rises too rapidly. causing an air embolism. which do not permit sufficient release of air. or has respiratory obstructions such as cysts. The pressure may cause intense pain beneath the rib cage and in the shoulders. major blood vessels. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. the expanding air may compress the respiratory passageways. making breathing difficult. When the alveoli of the lungs rupture because of traumatic injury or lung disease. or scar tissue. As a diver descends. Air bubbles can then enter the veins and capillaries of the circulatory system directly. the extra gas pressure is relieved by exhaling. The air the diver breathes is more dense and concentrated than the air breathed on the surface. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. and collapse blood vessels vital to circulation. This area contains the heart. the external pressure upon his or her body increases. main bronchi. or they can travel through the lung tissue to other areas of the body. mucus plugs. One pathway that the air can follow is through the lung tissue into the mediastinum. when he or she begins to ascend again. and the lungs begin to expand because the air inside has less pressure to contain it. the released air seeks an area of escape. While the diver remains deeply submerged. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. 157 . Air trapped in the mediastinum expands as the diver continues to rise. If the diver holds his or her breath. there is no difficulty. This usually occurs as a result of lung rupture. however. the external pressure decreases. the lungs become overinflated and rupture.7 Diseases and Disorders of the Respiratory System 7 heart and central blood vessels.

For example. and cyanosis (blue colouring of the skin). 158 . In many cases the cause of the paralysis cannot be determined. this can lead to herniation of the abdominal viscera through the diaphragm. In some persons the diaphragm may be incompletely formed at birth. The function of the diaphragm may be compromised when the lung is highly overinflated.7 The Respiratory System 7 The symptoms of mediastinal emphysema may range from pain under the breastbone. although some shortness of breath on exertion is often present. especially when the subject is recumbent (lying down). diaphragmatic fatigue may limit the exercise capability of affected persons. If there is respiratory or circulatory distress. the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. shock. as occurs in emphysema. respiratory failure. Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. and shallow breathing to unconsciousness. In cases in which the symptoms are not severe. bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air. the air will be absorbed by the body.

such as respiratory distress syndrome. decompression sickness. Carbon monoxide poisoning. such as asbestos and coal dust. 159 . In occupational disease. reducing exposure to the irritant relieves the symptoms of their condition. leading to cancer and substantial loss of lung function. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. many of which are acute in nature. causes respiratory disease in otherwise healthy workers. the lungs are exposed to the outside environment. First. and. In some cases of occupational exposure. however. A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. hence. For most affected persons. altitude sickness. In the case of allergies.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. exposure to harmful irritants. traumatic conditions. severe respiratory disease may ensue. Respiratory function can be severely compromised by a variety of other conditions. and drowning are other examples of acute conditions that can result in respiratory failure. For example. affected persons are highly sensitive to substances such as dust or pollen.

Although an initial episode can occur at any age. Adult asthma is sometimes linked to exposure to certain materials in the workplace. When asthma develops in childhood. In 160 . chest tightness. and grains. wood dusts. asthma may develop in response to allergens. which may be involved in any general inflammatory response. women are affected more often than men. and breathlessness that range in severity from mild to life-threatening. causing episodes of wheezing.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. and exercise may cause it as well. such as pollen. or sinusitis. nasal polyps. that may induce an allergic reaction. however. the walls of the bronchial tree contain smooth muscle that is very likely to be stimulated to contract if histamine is released by cells affected by the allergic reaction. The most common and most important of these is asthma. Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. Asthmatic episodes may begin suddenly or may take days to develop. aspirin. These substances provoke both allergic and nonallergic forms of the disease. boys being affected more often than girls. or animal dander. dust mites. Adults who develop asthma may also have chronic rhinitis. second. Among adults. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. the lung contains a very large vascular bed. coughing. approximately half of all cases occur in persons younger than age 10. third. such as chemicals. In adults. weather conditions. In addition. stress may exacerbate symptoms. and. but viral infections. it is often associated with an inherited susceptibility to allergens— substances.

Asthma is classified based on the degree of symptom severity. During an asthma attack. Consequently. and severe persistent. most of these cases.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. symptoms will subside if the causative agent is removed from the workplace. Inc. narrower passages (bronchioles) and finally into the tiny. Encyclopædia Britannica. which can be divided into four categories: mild intermittent. mild persistent. smooth muscles that surround the airways spasm. in general 161 . Although the mechanisms underlying an asthmatic episode are not fully understood. which results in tightening of the airways. terminal bronchial tubes. 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. air is obstructed from circulating freely in the lungs and cannot be expired. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. moderate persistent.

. which are involved in mediating airway constriction and inflammation. swelling and inflammation of the bronchial tubes. and excessive secretion of mucus into the airways.g. Agents that block enzymes called phosphodiesterases. A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. which suppress inflammation. These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). cromolyn sodium and nedocromil. and leukotriene modifiers. mucus-clogged airways act as a one-way valve (i. Long-term control medications include corticosteroids. which relax smooth muscle constriction and open the airways. and zileuton and zafirlukast. The obstruction of airflow may resolve spontaneously or with treatment. which are anti-inflammatory medications often prescribed for children. are in clinical trials. These 162 .7 The Respiratory System 7 it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system.. which are the most potent and effective anti-inflammatory medications available. such as shortacting beta2-agonists and ipratropium bromide.e. or they may be used to provide rapid relief from constriction of airways (quick-relief medications). These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi. which interrupt the chemical signaling within the body that leads to constriction and inflammation. long-acting beta2-agonists and methylxanthines (e. bronchodilators. Asthma medications are categorized into three main types: anti-inflammatory agents. theophylline). air is inspired but cannot be expired). The inflamed. or systemic corticosteroids. Quick-relief medications may include bronchodilators. which are bronchodilators. which are leukotriene modifiers.

In those areas. Air pollution. crowded living conditions. In addition to managing asthma with medications. too few to cause hookworm disease. particularly among children. 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. millions of people are infected with Necator americanus. a species of hookworm. However. exposure to secondhand smoke. can relieve symptoms of allergy and asthma. 163 . persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma. and even cockroaches have been blamed for the increase. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. The ability to recognize the early warning signs of an impending episode is important. smoking. Reasons for this dramatic surge in asthma cases. Further investigation of this “helminthic therapy” in larger sample populations is under way. in many underdeveloped tropical regions of the world. are not entirely clear. A person with this condition must be hospitalized to receive oxygen and other treatment. 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. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. Today asthma affects more than 7 percent of children and about 9 percent of adults. which may cause cardiovascular damage. the number of asthma cases has increased steadily. In developed countries and especially in urban areas.

may give rise to asthma. which irritates the small blood vessels and mucus-secreting glands. like other allergic diseases. shows a familial tendency and may be associated with other allergic disorders. studies have indicated that only one vaccine. 164 .7 The Respiratory System 7 There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. Although not yet successfully confirmed. In allergic persons contact with pollen releases histamine from the tissues. also known as allergic rhinitis. The most effective long-term treatment is immunotherapy. is a common seasonal condition caused by allergy to grasses and pollens. such as ragweed in North America and timothy grass in Great Britain. chiefly those depending upon the wind for cross-fertilization. such as dermatitis or asthma. nasal congestion. Antibiotics may also interfere with immune development. 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). pertussis vaccine. Hay Fever Hay fever. 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. 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. Hay fever. Seasonally recurrent bouts of sneezing. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. and tearing and itching of the eyes caused by allergy to the pollen of certain plants.

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. Broman—Root Resources 165 .

Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. If untreated. the condition may become chronic. with inflammation of the smaller bronchioles. on the eastern seaboard of Canada. and in France. budgerigars (parakeets). in the west of England. One of these illnesses is the so-called farmer’s lung. with shortness of breath persisting after the radiographic changes have disappeared. particularly proteins contained in the excreta of pigeons. Variously known as pigeon breeder’s lung or bird fancier’s lung. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). A similar group of diseases occurs in those with close contact with birds.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. alveolar wall edema. This causes an acute febrile illness with a characteristically fine opacification (clouding. In more chronic forms of the condition. after 166 . granulomas. or becoming opaque) in the basal regions of the lung on the chest radiograph. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. these represent different kinds of allergic responses to proteins from birds. or aggregations of giant cells. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. Farmer’s lung is common in Wisconsin. may be found in the lung. and there may be measurable interference with diffusion of gases across the alveolar wall. Airflow obstruction in small airways is present. and canaries.

occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 . An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. but sometimes the precise agent cannot be identified. or in response to a variety of other agents. 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.

or air sacs.7 The Respiratory System 7 irritants. Inhaled dust collects in the alveoli. shortness of breath. and infections of the already damaged lung can accelerate the disease process. and cough. while milder irritants produce symptoms of lung disease only with massive exposure. and emphysema in the most severe cases. the toxic effects of certain types of dust. tin. silica. As little as 5 or 6 grams (about 0. Graphite. of the lung. clay. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. the early symptoms of mild pneumoconioses include chest tightness. and aluminum dusts can cause a more severe pneumoconiosis. Pneumoconioses associated with these substances usually result only from continued exposure over long periods.2 ounce) in the lung can produce disease. lung function is seriously impaired. If enough scar tissue forms. beryllium. Asbestos. progressing to more serious breathing impairment. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. barium. and coal dusts are other inorganic substances known to produce pneumoconiosis. encountered in numerous occupations. Typically. although silica exposure is also involved in many cases. produce grave reactions. chronic bronchitis. The total dust load in the lung. and the clinical symptoms of pneumoconiosis are manifested. The type and severity of disease depends on the composition of the dust. chromate. notably silica and asbestos. is the most common cause of severe pneumoconiosis. Among inorganic dusts. usually over a prolonged period of time. iron. small quantities of some substances. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. often after relatively brief 168 .

caused by fibres of cotton. ammonia.) The disease occurs most commonly in miners. sandblasting. the patient may recover completely or may suffer from chronic bronchitis or asthma. The chemicals themselves may scar the delicate lung tissues. malt. which are quickly absorbed by the lining of the lungs. and their irritant effect may cause large amounts of fluid to accumulate in the lungs. stimulate histamine release. acid. (Silica is the chief mineral constituent of sand and of many kinds of rock. and it remains one of the most common dust-induced respiratory diseases in the developed world. Histamines cause the air passages to constrict. The 169 . Brown lung disease in textile workers is also a form of pneumoconiosis. having been recognized in knife grinders and potters in the 18th century. nitrogen dioxide. or hemp that. Chemical irritants that have been implicated in lung disease include sulfur dioxide. and chloride. and barley can produce lung disease through a severe allergic response within a few hours of exposure. Asbestosis has also been associated with cancers of the lung and other organs. impeding exhalation. Once exposure to the chemical ceases. Silicosis is one of the oldest industrial diseases. even in previously nonallergic persons. flax. Silicosis Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. when inhaled. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. Prolonged exposure to organic dusts such as spores of molds from hay. mushrooms.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 exposure to massive amounts of dust. stonecutters. sugarcane. tunnelers. and workers whose jobs involve grinding. and buffing. quarry workers. In most instances. polishing.

In the past a large proportion of sufferers of silicosis died of tuberculosis. In the actual disease process. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. cannot be digested by the macrophages and instead kill them. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. 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. and pneumonia. There is no cure for silicosis. Silicosis predisposes a person to tuberculosis. emphysema. Only very small silica particles less than 10 microns (0. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. and the abdominal lymph nodes.0004 inch) in diameter penetrate to the finer air passages of the lungs. since there is no effective treatment. difficulty in breathing. also known as coal-worker’s pneumoconiosis. The symptoms of silicosis are shortness of breath that is followed by coughing. Lung volume is reduced. Black Lung Black lung.000 particles of silica per cubic foot (about 210. Silica particles. however. These whorls of fibrous tissue may spread to involve the area around the heart. the openings to the lungs. and particles of one to three microns do the most damage. control of the disease lies mainly in prevention. called macrophages. that serve to protect the body from bacterial invasion. and weakness. is a respiratory disorder caused by repeated inhalation of 170 .000 per litre) of air. and. and gas exchange is poor.000. though this has changed with the availability of drug therapies for that disease.

Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. and later in flooring. and as a fire protectant sprayed inside buildings. brake linings. however. ceiling tiles. led to a virtual epidemic of asbestos-related disease 20 years later. The disease is most commonly found among miners of hard coal. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. first described lung disease in coal miners in the 16th century. 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. tuberculosis is also more common in victims of black lung. The first disease recognized to be caused by asbestos was asbestosis. but it also occurs in soft-coal miners and graphite workers. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to 171 . Georgius Agricola.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 coal dust over a period of years. and the extent of disease is clearly related to the total dust exposure. a German mineralogist. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. Onset of the disease is gradual. and it is now widely recognized. which causes similar symptoms. It may be the best known occupational illness in the United States. whether coal itself is solely responsible for the disease. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. The early stages of the disease (when it is called anthracosis) usually have no symptoms. There is strong evidence that tobacco smoking aggravates the condition. It is not clear. as coal dust often is contaminated with silica.

Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. As far as is known.7 The Respiratory System 7 thickening of the pleura. when both cigarette smoking and asbestos exposure occurred. thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. although in occasional cases pleuritis is very aggressive and thus may produce symptoms. there was a major increase in the risk for lung cancer. inhalation of asbestos remains a significant risk for the workers removing the material. Asbestos has been suspected to play a role in stimulating certain cellular events. It is not yet understood exactly why asbestos devastates the tissues of the lungs. But exposure to any type of asbestos is believed to increase the risk of lung cancer. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. a blue asbestos that comes from South Africa. These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. The risk of mesothelioma in particular appears to be much higher if crocidolite. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people. is inhaled than if chrysotile is inhaled. and. Not all types of asbestos are equally dangerous. especially when associated with cigarette smoking. All 172 . but survival after diagnosis is less than two years. all the respiratory changes associated with asbestos exposure are irreversible. Malignant mesothelioma is rare and unrelated to cigarette smoking. In most cases. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer.

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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.

to an increased respiratory rate. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. a clot is replaced with 177 . When severe. conditions arising from exposure to extremes in atmospheric pressure. This occurs most often during a postoperative period when the affected individual is immobilized in bed. in which the pressure in the main pulmonary artery is persistently increased. these changes are known as a pulmonary infarction. and occasionally some pleuritic pain over the site of the infarction. In addition. The causative factors of these conditions may include accidents. when the infarction is massive. Early mobilization after surgery or childbirth is considered an important preventive measure. Circulatory Disorders The lung is commonly involved in disorders of the circulation. slight fever. Over time. The consequences of embolism range from sudden death. and metabolic disorders. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. toxic gases. ranging from poor pulmonary circulation to carbon monoxide poisoning.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. environmental pollutants. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. comprise a diverse group of diseases and disorders. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. which occurs during mountain climbing and diving. which has usually formed in the veins of the legs or of the pelvis.

Prostacyclin can sometimes be given in oral or inhaled forms. causing shortness of breath on exertion and. usually after increasing disability with severe shortness of breath. usually as a consequence of coronary arterial disease. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. In addition to chest X-rays and basic pulmonary function tests. a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. In primary pulmonary hypertension. with consequent shortness of breath. lung transplantation is necessary. long-term evaluation and treatment. affected individuals require careful. While some medications such as calcium channel blockers may be taken orally. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. In some cases. thereby relieving symptoms of breathlessness. The obstructing lesions can be surgically removed in some instances. right ventricular heart failure.7 The Respiratory System 7 an adherent fibrous material in the pulmonary arteries. ultimately. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. a condition of unknown origin. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. follows left ventricular failure. When the 178 . and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart.

it also sometimes develops in full-term infants. These changes contribute to the shortness of breath and account for the blood staining of the sputum.5 kg. In infants it is also called hyaline membrane disease. Although respiratory distress syndrome occurs mostly in premature. or approximately 5. Before the advent of effective treatment. The syndrome was formerly the leading cause of death in premature infants.5 pounds). low-birth-weight infants (those weighing less than 2. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. The disorder arises because of a lack of surfactant. and abnormally low levels of oxygen in the arterial blood. It is characterized by extremely laboured breathing. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. This complication is especially common in premature newborns. particularly those born to diabetic mothers.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). respiratory distress syndrome of infants was frequently fatal. 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. which does the work of the lungs by oxygenating the 179 . but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. cyanosis (a bluish tinge to the skin or mucous membranes).

although superimposed infection or multiple organ failure can result in death. but not all. widespread bilateral lung injury. Life-support treatment with assisted ventilation rescues many patients. This episode spurred renewed attention to this problem. 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. In adults. Many. This syndrome is known as acute respiratory distress syndrome of adults. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. which had been intermittently considered since the 14th century 180 . bacterial or viral pneumonia. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. Many causes of respiratory distress syndrome of adults have been identified.000 people during that week and the subsequent three weeks. exposure of the lung to gases. Acute respiratory distress syndrome carries about a 50 percent mortality rate. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. 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. Most children who survive have no aftereffects. of the victims already had chronic heart or lung disease. Recovery and repair of the lung may take months after clinical recovery from the acute event.7 The Respiratory System 7 blood and removing carbon dioxide. aspiration of material into the lung (including water in near-drowning episodes).

com/Jupiterimages 181 . the factor most responsible for the pollution. This begins with the emission Air pollution begins as emissions from sources such as industrial smokestacks. common in many cities using coal as heating fuel.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 in England. respiratory tract infections in the young and old. 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. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. The large number of automobiles in that city. is associated with excess mortality and increased prevalences of chronic bronchitis. and finally the passage of legislation banning open coal burning. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles. Photos. together with the bright sunlight and frequently stagnant air. and possibly lung cancer. This form of pollution.

exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. and finally. Such exposures are common in the lives of millions of people. Bangkok. followed by the formation of nitrogen dioxide by oxygenation.12 part per million. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. Ozone is the most irritant gas known. 182 . Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. chest irritation with cough. and São Paulo. Eye irritation. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. through a complex series of reactions in the presence of hydrocarbons and sunlight. In developed countries. which begins as emissions of nitrogen oxides. including Mexico City. and repeated exposures may lead to lung cancer.7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. and the impact of these exposures is an area of intense scientific investigation. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. These levels are commonly exceeded in many places. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. and possibly the exacerbation of asthma occur as a result. The indoor environment can be important in the genesis of respiratory disease. In developing countries.

The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. leaving only 60 percent available to bind to oxygen). 183 . For this reason. Carbon monoxide is produced by incomplete combustion. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). A 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. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. including combustion of gas in automobile engines. Judgment is also impaired. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. a condition in which hemoglobin is deficient. as part of his detailed analysis of atmospheres in underground mines. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. the subject feels dizzy and is unable to perform simple tasks. 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.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide.

among others. Alkalosis and Hyperventilation Alkalosis is an abnormally low level of acidity. and renal failure. or by certain medications that suppress respiration in excessive doses.7 The Respiratory System 7 Acidosis Acidosis is an abnormally high level of acidity. including the blood. There are two primary types of acidosis: respiratory and metabolic. such as general anesthetic agents. congestive heart failure. pulmonary embolism. including the blood. Metabolic alkalosis results from either acid loss. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. During hyperventilation the rate of 184 . Causes of metabolic acidosis include uncontrolled diabetes mellitus. shock. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). 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. Alkalosis may be either metabolic or respiratory in origin. which may be caused by anxiety. or pneumonia. Respiratory alkalosis results from hyperventilation. in the body fluids. certain drugs or poisons. This may be caused by severe acute or chronic lung disease. Hyperventilation is defined as a sustained abnormal increase in breathing. or bicarbonate gain. or low level of alkalinity. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. asthma. or high level of alkalinity. in the body fluids. such as pneumonia or emphysema. Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs.

accumulation of fluid in the alveolar spaces can interfere with gas exchange.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. Encyclopædia Britannica. 185 . In addition. such as respiratory acidosis or hyperventilation. Inc. causing symptoms such as shortness of breath. Imbalances in the exchange of these gases can lead to dangerous respiratory disorders.


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.


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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
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

Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. small amounts of the gases that are present in the air. A fatal form of barotrauma can occur in submariners and divers. face. or under the skin of the neck. In certain cavities of the body. such as the eardrum. the pleural spaces. When a pilot ascends to a higher altitude. in solution. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). and intestines. and torso. At atmospheric pressure the body tissues contain. underwater divers. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). such as the ears. and these dissolved gases come 190 . For example.7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. lungs. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. there are air pockets that either expand or contract in response to changes in pressure. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. Pilots of unpressurized aircraft. 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. sudden expansion of air trapped within the thorax can burst one or both lungs. sinuses. 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. the external pressures upon his or her body decrease. however. Another form of barotrauma may occur during mechanical ventilation for respiratory failure.

the “chokes. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled. Bubbles forming in the brain.” The major component of air that causes decompression maladies is nitrogen. The nervous system is composed of about 60 percent lipids.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 out of solution. The gases then pass to the respiratory tract and are exhaled from the body. speech defects. the gases have time to diffuse from the tissues into the bloodstream. Shallow. Conversely. as the affected person commonly is unable to straighten joints. the excess nitrogen is released. When bubbles accumulate in the joints. 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. signals the onset of pulmonary decompression sickness. Nitrogen is much more soluble in fatty tissue than in other types. The term bends is derived from this affliction. pain is usually severe and mobility is restricted. often associated with a sharp retrosternal pain on deep inspiration. and personality changes. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). numbness. Therefore. If the ascent is slow enough. When the pressure decreases. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. rapid respiration. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s 191 . spinal cord. nausea. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture.

Usually these symptoms pass in 10 to 20 minutes. is a type of barotrauma involving compression of the lungs and thoracic cavity. Other symptoms include chest pain. Too much air causes rupture of lung tissue. 192 . It most commonly occurs during a breath-holding dive underwater. Because the lung tissue is elastic and interspersed with tubules and sacs of air. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. The outer linings of the lungs (pleural sacs) may separate from the chest wall.7 The Respiratory System 7 itches. the air inside the lungs is compressed. 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. and severe shock. a burning sensation while breathing. and the lung may collapse. Excessive coughing and difficulty in breathing. or lung squeeze. while too little air causes compression and collapse of the lung walls. an increase in pressure causes air spaces and gas pockets within the body to compress. indicate nitrogen bubbles in the respiratory system. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. If compression continues. the lung shrinks to about one-fourth its size at the surface. If one descends to a depth of about 30 metres (100 feet). but this process is not always able to reverse damage to tissues. During the descent. known as the chokes. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. Thoracic Squeeze Thoracic squeeze.

Artificial respiration may be necessary if the breathing has stopped.000 metres (3. Drowning Drowning is suffocation by immersion in a liquid. 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. It is now known that victims immersed for an hour or longer may be totally salvageable.300 feet). although they lack evidence of life. physically and intellectually. Until recently. These aquatic mammals have been found to have more elastic chest cavities than humans. having no measurable vital signs—heartbeat. do not separate from the chest wall. pulse. Deprived of oxygen the victim stops struggling. which can be relieved by ascending. The sperm whale is reported to dive to about 1. but eventually it ceases. the diver may have difficulty in breathing. and gives up the remaining tidal air in his or her lungs. or breathing—at the time of rescue.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. Any symptoms of thoracic squeeze call for prompt medical attention. There the heart may continue to beat feebly for a brief interval. may exhale frothy blood. loses consciousness. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. usually water. more than 10 times the depth that humans can tolerate. If the thoracic squeeze has been sufficient to cause lung damage. even when reduced. A fuller appreciation of the 193 . and their bodies are adapted to use the gases in the bloodstream more conservatively. their lungs. and may even become unconscious. 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.

quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. enhances survival during submersion. thus permitting seagoing mammals to hunt for long periods underwater. Up to 15 percent of drownings are “dry. abdomen.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. Scientists have determined that vestiges of the reflex persist in humans. in other respects it performs normally. and surface areas of the body to the heart and the brain. the volume of fluid entering the lungs rarely exceeds a glassful. 194 . Even though the heart functions at a slower rate. A natural biological mechanism that is triggered by contact with extremely cold water. so that many people who once would have been given up for dead are being saved. When aspiration does occur. It diverts blood from the limbs. actual aspiration of water into the lungs may or may not occur. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. Often.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. In this suspended state. known as the mammalian diving reflex. The mechanism is powerful in children. despite a total absence of respiratory gas exchange. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat.

7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. survival following hypothermic coma is almost 75 percent. 195 . so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia. 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). None of these effects is imminently life-threatening. slows the heart rate.6 °F (17 °C) have survived. Such warmwater drownings occur commonly in domestic bathtubs.” “Lifeless” immersion victims with core temperatures as low as 62. and promotes unconsciousness. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues.

Today. especially in the area of disease prevention. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. particularly concerning techniques employing X-ray imaging or endoscopy. Likewise. have contributed to improvements in the diagnosis and evaluation of respiratory disease. or respiratory medicine. This expansion of scientific understanding has enabled important progress in respiratory medicine. and pathology of the human respiratory system is known as pulmonology.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. A cough productive of sputum is the most important manifestation of inflammatory or 196 . This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. 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. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. many technological advances. physiology. In addition. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree.

or a tumour. it may also indicate the presence of inflammation. in which there is irreversible lung damage. playing golf. More often. particularly in the first two hours after awakening in the morning. such as walking up a flight of stairs. as when a foreign body is inhaled into the trachea. if the right ventricle that pumps blood through the lungs is functioning normally. This sensation. The shortness of breath may vary in severity. capillary damage. or with the onset of a severe attack of asthma. may also cause severe and unremitting dyspnea. Hemoptysis is also a classic sign of tuberculosis of the lungs. resulting from occupational lung disease or arising from no identifiable antecedent condition. may arise acutely.7 Approaches to Respiratory Evaluation and Treatment 7 malignant diseases of the major airways. Severe fibrosis of the lung. Although it may result simply from an exacerbation of an existing infection. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. the lung capillaries become engorged. commonly. and fluid may accumulate in 197 . It may become so severe as to immobilize the victim. What is noted is a slowly progressive difficulty in completing some task. or shortness of breath. and tasks such as dressing cannot be performed without difficulty. of complex origin. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. 30 to 60 ml of sputum are produced in a 24-hour period. it is insidious in onset and slowly progressive. The second most important symptom of lung disease is dyspnea. it is constantly present. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. or walking uphill. and. of which bronchitis is a common example. but in diseases such as emphysema. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. When this occurs.

A wheeziness in the chest may be heard. which leads to acute congestion of the affected part. dyspnea. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. of the toes) called “clubbing. and chest pain—may be added several others. To these major symptoms of lung disease—coughing. or by a tumour that arises from the pleura itself. rarely. Chest pain may be an early symptom of lung disease. such as a mesothelioma. such as occurs in asthma. pulmonary embolism. In addition. but absence of the symptom does not mean that serious lung disease is not present. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. 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. pain of this severity is rare. a small lung cancer that is not obstructing an airway does not produce shortness of breath. severe chest pain may be caused by the spread of malignant disease to involve the pleura. a condition known as a pleural effusion. Severe. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. can cause pleurisy. Some diseases of the lung are associated with the swelling of the fingertips (and.7 The Respiratory System 7 small alveoli and airways. but it is most often associated with an attack of pneumonia. Fortunately. For example. It is commonly dyspnea that first causes a patient to seek medical advice. The pain disappears when fluid accumulates in the pleural space. since. diffuse 198 . Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). This is caused by narrowing of the airways. for example. Acute pleurisy with pain may signal a blockage in a pulmonary vessel.

or jaundice from liver involvement may all be the first evidence of a primary lung cancer. In the case of lung cancer. Loss of appetite and loss of weight. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs.7 Approaches to Respiratory Evaluation and Treatment 7 fibrosis of the lung from any cause. the patient may feel as one does when convalescent after an attack of influenza. and some symptoms apparently unrelated to the lung. since a peripheral neuropathy may also be the presenting evidence of these tumours. may be diverse indicators of lung disease. a hip fracture from bone metastases. the first symptom may be a swelling of the lymph nodes that drain the affected area. unusual fatigue. Because the symptoms of lung disease. this unusual sign may disappear after surgical removal of the tumour. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. The generally debilitating effect of many lung diseases is well recognized. as may sensory changes in the legs. particularly the small nodes above the collarbone in the neck. for example. cerebral signs from intracranial metastases. may be conscious of only a general feeling of malaise. are variable and nonspecific. such as mild indigestion or headaches. general psychological depression. and lung cancer. Not infrequently. a 199 . In some lung diseases. as it may reveal the presence of an area of inflammation. especially in the early stage. a disinclination for physical activity. A person with active lung tuberculosis or with lung cancer. Methods of inVestigation Physical examination of the chest remains important. or seemingly minor symptoms as the first indication of disease. Not infrequently. Thus. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints.

Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. in the case of perfusion scanning. or injected. percussion to gauge the resonance of the underlying lung. tender areas. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. a radioactive tracer molecule is either inhaled. Methods of examination include physical inspection and palpation for masses. MRI is useful for imaging the heart and blood vessels within the 200 . the lung tissue. This technique produces a complete picture of the lungs by using X-rays to create two-dimensional images that are integrated into one image by a computer. While the resolution of computerized tomography is much better than most other visualization techniques. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. In these techniques. The sounds detected with a stethoscope may reveal abnormalities of the airways. and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds. The ventilation scan allows visualization of gas exchange in the bronchi and trachea.7 The Respiratory System 7 pleural effusion. and abnormal breathing patterns. sputum examination for malignant cells is occasionally helpful. because the technique is not well suited to imaging air-filled spaces. or the pleural space. in the case of ventilation scanning. and the perfusion scan allows visualization of the blood vessels in the lungs. or an airway obstruction. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli.

Spirometry. which is often used in field studies. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. By feeding a surgical instrument through a special channel of the bronchoscope. Tests of exercise capability. physicians can collect fluid and small tissue samples from the airways. and major bronchi. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function. Ventilatory capability can be measured with a peak flow meter.7 Approaches to Respiratory Evaluation and Treatment 7 thorax. during. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. in which workload. total ventilation. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. or the pressure required to inflate it. are useful in assessing functional impairment and disability. the stiffness of the lung. and gas exchange are compared before. and after exercise. trachea. airflow resistance. 201 . which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. More complex laboratory equipment is necessary to measure the volumes of gas in the lung. the distribution of ventilation within the lung. and the rate of gas transfer across the lung.

and (2) those measuring respiratory function. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. or the transfer of gas between the alveoli and the blood. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs).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.

Ventilation tests. who discovered X-rays in 1895. This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. the resting lung volume. maximum air volume that can be expelled after a maximum inspiration. One of the most common screening roentgenograms is the chest film. vital capacity. of the lungs. forced expiratory volume (FEV). air remaining within the chest after a maximal expiration. tidal volume. all the other volumes may be recorded with a spirometer. maximal flow rate of a single expelled breath. volume of a breath. and maximal expiratory flow rate (MEFR). functional residual capacity (FRC). maximal air volume expelled in 12 to 15 seconds of forced breathing. breathing movements may also be registered graphically on a spirogram.7 Approaches to Respiratory Evaluation and Treatment 7 volume (RV). and total lung capacity (TLC). The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. Tests of respiratory function include the measurement of blood oxygen and carbon dioxide and the rate at which oxygen passes from the alveoli into the small blood vessels. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. include maximal voluntary ventilation (MVV). or capillaries. which measure the capacity of the lungs to move air in and out. Except for the residual volume. maximum air volume expelled in a time interval. Chest X-ray X-ray imaging is a valuable diagnostic technique used in medicine. air volume within the chest in full inspiration. which is measured by a dilution method. expressed in litres of air per minute. or air within the chest at the end of a quiet expiration. taken to look for infections such as 203 .

Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. Pulmonary embolism is caused by a clot or an air bubble that has become lodged within a vessel or by the accumulation of fat along the inner walls of the vessel. This approach may be taken for patients with advanced or rapidly spreading lung cancer. the blockage of one of the pulmonary arteries or of a connecting vessel. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 . A scanner that contains a radiation-sensitive camera is then used to collect images of the gamma rays emitted from the tracer as it circulates through the lungs.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. or VQ (ventilation quotient) scan. Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. but. unfortunately. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. 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. To track the movement of air. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. is a test that measures both air flow (ventilation) and blood flow (perfusion) in 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.

The appearance of hot spots. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent 205 . Bronchoscopy Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. the levels of radioactivity are exceptionally low and pose a very small risk to patients. he or she may subsequently undergo more invasive procedures. the ventilation and perfusion scans match for a person with healthy lungs. Nutrient deprivation renders the tissue highly susceptible to death. In both ventilation and perfusion scans. or areas where the tracers become highly concentrated and therefore produce bright areas in the images.7 Approaches to Respiratory Evaluation and Treatment 7 with technetium). Although the tracers used in lung ventilation/perfusion scanning are radioactive. the tissues affected will be either oxygen.or blooddeprived. Thus. 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. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan. In general. and another set of images is taken with the scanner. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. normal air and blood flow are reflected in the even distribution of tracers within the lungs. including angiography. a mismatch between the two scans is indicative of disease. highlight places within the lungs where air or blood have accumulated abnormally. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism.

7 The Respiratory System 7 The trachea and major bronchi of the human lungs. 206 . Inc. Encyclopædia Britannica.

Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. because of their ability to bend and twist. blood) to be removed during an examination. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. known as a rigid bronchoscope. The second type of scope. they remain superior for specific applications. 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.g. 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. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. to deliver certain therapeutic agents directly into the lungs. There are two types of bronchoscopes. consists of a metal tube that has a wide suction channel. Bronchoscopy is also employed to remove foreign objects from the airways.. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. Flexible scopes. which enables large volumes of fluid (e. 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. and to assist in the placement of stents (tubes. both flexible and rigid scopes have a channel through which instruments can be passed. 207 .

Bleeding is especially common following biopsy. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity. serving as one of the primary 208 . there are several important risks associated with the bronchoscopy procedure itself. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. upon waking. rigid bronchoscopy. and thymus gland. the movement of a bronchoscope through the airways often scratches superficial tissues. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. trachea. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). as well as a set of lymph nodes. For example. which occurs when the instrument is not sanitized properly. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs. bleeding subsides without the need for medical intervention.7 The Respiratory System 7 Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. causing a condition known as pneumothorax. In contrast. including nausea and vomiting. In addition. Mediastinoscopy Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. esophagus. necessitates the use of general anesthesia. In most cases. which can cause side effects in some people. mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. causing them to bleed. because of the discomfort caused by the device. Because the region of the mediastinum contains the heart. however.

This may also be performed for other tissues in the region that display signs of disease. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. and the procedure is associated with a very low risk of complications. In cancer staging. flexible instrument—is then passed through the incision and into the space between the lungs. Staging involves the investigation of cells to assess the degree to which cancer has spread. The biopsy samples are then investigated for evidence of abnormalities. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. such as abnormal growths or inflammation. including computerized axial tomography and positron emission tomography. This step of the procedure is known as mediastinotomy. the doctor is able to investigate the surfaces of the various structures. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. which is performed under general anesthesia. a surgeon first makes a small incision in the patient’s neck. Most patients recover within several days following mediastinoscopy. By carefully maneuvering the scope in the space. light-emitting. infection. A mediastinoscope—a thin. Severe complications— such as bleeding. immediately above the sternum. During mediastinoscopy.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. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. particularly for cellular defects associated with cancer and for the presence of infectious organisms. 209 .

There are different methods of treatment employed in respiratory therapy. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. Therapy may involve the administration of gases for inhalation. and maintenance of mechanical ventilators. Chest percussion. produces vibrations that help to loosen and mobilize secretions. mucolytics. Medications. such as bronchodilators. A mixture of helium and oxygen is used to treat some diseases of airway obstruction. 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. as in treatment of cystic fibrosis. and antibiotics. One of the conditions frequently dealt with is obstruction of breathing passages. Oxygen may be administered in controlled amounts to assist laboured breathing. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. respiratory therapists are experts in the setup. 210 . or a fog (as in an oxygen tent or a croup tent).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. adjustment. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. performed manually or by means of a handheld percussor or vest. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. In addition. each of which may be tailored to a specific disease. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. hot steam. Ultrasonic equipment may be used to propel very fine particles directly into the lungs.

although capillaries. decongestants. there are three groups. thus reducing blood flow to the inflamed areas. veins. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls.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. antihistamines. That is. the arterioles. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. When administered in nasal sprays or drops or in devices for inhalation. Decongestants are sympathomimetic agents. However. they mimic the effects of stimulation of the sympathetic 211 . these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. and larger arteries respond to some degree. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. decongestants and antihistamines are available over the counter. In countries such as the United States. The relative safety and efficacy of these drugs has made them generally reliable medications. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. that are of particular importance in the routine treatment of respiratory illness. due to the emergence of resistant organisms. and antibiotics. and thus they are used by many people. The constricting action chiefly affects the smallest arteries.

causing anxiety. headache. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. dizziness. and naphazoline hydrochloride.000 years. One of the chief drugs of the group is epinephrine. Because none of them has a sustained effect. they must be used repeatedly. amphetamine and several derivatives. thereby preventing histaminetriggered reactions under such conditions as stress. Ephedrine and other decongestants are made by chemical synthesis. or heart palpitations. inflammation. and allergy. an alkaloid originally obtained from the leaves of ma huang. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. any of several species of shrubs of the genus Ephedra. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. results in absorption into the bloodstream. which has been used in Chinese medicine for more than 5. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . They include phenylephrine hydrochloride.7 The Respiratory System 7 division of the autonomic nervous system. following its release from certain large cells (mast cells) within the body. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. too frequent use. in which epinephrine constricts the blood vessels of the skin. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. however. insomnia. The oldest and most important decongestant is ephedrine.

the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. antihistamines can control certain allergic conditions. more specific. Used in sufficiently large doses. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. and most are rendered inactive by monoamine oxidase enzymes in the liver. Antihistamines are not usually beneficial in treating the common cold and asthma. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. Antihistamines are readily absorbed from the alimentary tract. In 1942. and dryness of the mouth. tested later and found to be more potent. If a patient’s condition does not improve after three days of treatment with antihistamines. 213 . More than 100 antihistaminic compounds soon became available for treating patients. The development of these antihistamines dates from about 1937. Anilinetype compounds. it is unlikely that he or she will benefit from them. nearly all antihistamines produce undesirable side effects. subsequently. headache. compounds that were more potent. Other side effects include gastrointestinal irritation. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. The most common side effect in adults is drowsiness. and less toxic were prepared. The first antihistamines were derivatives of ethylamine.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. and certain sensitivity reactions respond well. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. Nasal irritation and watery discharge are most readily relieved. were too toxic for clinical use. blurred vision. among them hay fever and seasonal rhinitis. itching. Persons with urticaria. edema.

Antibiotics known as macrolides (e. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. erythromycin. clarithromycin. These drugs are usually administered orally. the bacillus responsible for diphtheria. at a high enough concentration to be effective (but not cause side effects). azithromycin) are particularly effective in the treatment of bacterial respiratory infections. whereas others. Macrolides. and for a sufficient length of time to ensure that the infection is totally eradicated. They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). but they can be given parenterally. Oxygen therapy is used for acute conditions.7 The Respiratory System 7 During the 1970s an H2-blocking agent. and they are especially important in the treatment of bacterial respiratory infections. act against a broad spectrum of different bacteria. Compounds of this class suppress histamine-induced gastric secretion and have proved extremely useful in treating gastric and duodenal ulcers. cimetidine (Tagamet) was introduced.g. Some are highly specific. which inhibit bacterial protein synthesis. Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. in which tissues such as the 214 . Oxygen Therapy The medical administration of oxygen is an important means of treating respiratory disease. such as the tetracyclines. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era.. are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin. Antibiotics vary in their range of action.

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.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. In emergency situations. known as hyperbaric oxygen therapy (HBOT). oxygen may be delivered through a face mask or through a nasal cannula. Another form of therapy. Some patients may require oxygen administration via a transtracheal catheter. 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. home oxygen therapy may be prescribed by a physician. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. however. For patients affected by chronic lung diseases. a device inserted into the nostrils that is connected by tubing to an oxygen system. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. HBOT has been promoted as an alternative therapy for certain conditions. the high concentrations of oxygen made available to tissues have been shown to help stimulate the growth of new blood vessels (angiogenesis) in healing wounds and to slow the progression of infections caused by certain anaerobic bacteria. In both the hospital and the home settings. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). In addition. portable compressed-gas oxygen cylinder. 215 . These applications are controversial. such as chronic obstructive pulmonary disease (COPD). which is inserted directly into the trachea by way of a hole made surgically in the neck.

a measure known as the flow rate. blood is drawn from an artery. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood 216 . Oxygen concentrators. The stored oxygen can then be used by the patient when needed and is readily replenished. When it is released under pressure from cold storage. In the ABG test. Large stationary and small portable gas cylinders can be used in the hospital or the home. generally placed over the end of a finger. oxygen. which maintain oxygen under high pressure and require the use of a regulator to modulate the flow of gas from the cylinder to the patient. Oxygen also can be stored as a highly concentrated liquid. Stationary and portable oxygen concentrators have been developed for use in the home. Liquid oxygen can be stored in small or large insulated containers. which draw in surrounding air and filter out nitrogen. and carbon dioxide levels are measured. 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. which can be refilled at pharmacies or by delivery services. Oxygen turns to liquid only when it is kept at very cold temperatures.7 The Respiratory System 7 There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. which necessitates more-frequent cylinder replacement. Flow rate is determined based on measurements of a patient’s blood oxygen levels. In pulse oximetry. provide a method of storing oxygen at concentrations greater than that occurring in ambient air. Oxygen is usually administered in controlled amounts per minute. and blood acidity. Two tests that are commonly used to assess the concentration of oxygen in the blood include the arterial blood gas (ABG) test and the pulse oximetry test. a probe. Another form of oxygen storage is in compressed-gas cylinders. as opposed to releasing gas constantly. it is converted to a gas.

However. HBOT is associated with an increased risk of barotrauma of the ear. adverse physiological effects may ensue if the flow rate is too high. leading to the damage of healthy tissues. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. For example. In general. such as with the drug bleomycin. it does not appeal to some patients. which can lead to tissue dysfunction and cell death. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. Compressed-gas cylinders present a significant safety hazard in the home as well. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. Also. Bronchopulmonary dysplasia. For example. a chronic disorder affecting infants. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity.7 Approaches to Respiratory Evaluation and Treatment 7 that are carrying oxygen. a response that is amplified in the presence of excess oxygen. if they are not secured and stored 217 . The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD. Excess oxygen flow also can result in conditions such as barotrauma. Likewise. If oxygen flow rate is too low. oxygen therapy does not alter the progression of lung disease. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species.

suffocation. which has been found to be more effective than the manual methods used in the past. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. Artificial Respiration Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. throat. Such techniques. and electric shock. 218 . Likewise. choking. they may cause explosions. can prevent some deaths from drowning. strangulation. The person using mouth-to-mouth breathing places the victim on his back. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights.7 The Respiratory System 7 properly. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. Furthermore. carbon monoxide poisoning. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. oxygen can readily spread fire. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1. if applied quickly and properly. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. candles. lifts the lower jaw forward and upward to open the air passage. or other sources of ignition. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. establishing and maintaining an open air passage from the upper respiratory tract (mouth. clears his mouth of foreign material and mucus. and pharynx) to the lungs and 2.

Stockbyte/Getty Images 219 .7 Approaches to Respiratory Evaluation and Treatment 7 Mouth-to-mouth breathing is the most effective means of manual artificial respiration.

liver. Thoracentesis Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. and lung infections. If the victim is a child. It is most often used to diagnose the cause of pleural effusion. Prior to thoracentesis. such as tuberculosis and pneumonia. a needle is inserted through the chest wall and into the effusion site in the pleural space. permitting the victim to exhale. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. such as chest X-rays or computerized axial tomography chest scans. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. including heart failure. Once the needle is inserted. the results of chest percussion and imaging tests. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. the rescuer may cover both the victim’s mouth and nose. as well as to prevent further complications associated with the condition. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. including infectious organisms.7 The Respiratory System 7 and clamps the nostrils. The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. He then alternately breathes into the victim’s mouth and lifts his own mouth away. tumours. In the subsequent thoracentesis procedure. particles such 220 . the abnormal accumulation of fluid in the pleural space. For diagnostic applications. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs. Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion. and spleen. including pleural empyema. including the lungs.

tissue injury arising from radiation therapy for cancer. Pressures 221 . 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. which occurs when a needle punctures the lungs. generally lasting about 10 to 15 minutes. The results of these analyses frequently warrant further diagnostic testing. More serious complications include pneumothorax. Thoracentesis is contraindicated in persons with bleeding disorders (i. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate. coagulopathy). or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks.7 Approaches to Respiratory Evaluation and Treatment 7 as asbestos. However. carbon monoxide poisoning. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. Thoracentesis is a relatively quick procedure. leading to a drop in blood pressure and fainting (syncope). which are suggestive of mesothelioma or lung cancer. the accumulation of air in the pleural space. particularly upon detection of cancerous cells. gas gangrene resulting from infection by anaerobic bacteria. Hyperbaric Chamber A hyperbaric chamber. and aberrant stimulation of the vasovagal reaction. also known as a decompression chamber (or recompression chamber). for several hours afterward patients are often observed for the manifestation of adverse effects.e. Experimental compression chambers first came into use around 1860.. Air. and tumour cells. another breathing mixture. gas embolism. Minor complications associated with thoracentesis include pain and cough. In its simplest form. and wounds that are difficult to heal.

Chris McGrath/ Getty Images used for medical treatment are usually 1. 222 .7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. In the treatment of carbon monoxide poisoning. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). which increases oxygen availability to the body in therapeutic treatment. In the treatment of decompression sickness. or from a combination of the two.5 to 3 times higher than ordinary atmospheric pressure. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. for example. a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues.

emphysema. With proper selection of donor organs and proper transplantation technique. often have also suffered lung injury or lung infection. Availability of donor lungs is sharply limited by the number of suitable donors. which presumably would leave the lungs intact. the techniques are being pursued aggressively in specialized centres.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. for example. Persons severely disabled by cystic fibrosis. many people who die of severe head injuries. sarcoidosis. 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 . Brochiolitis obliterans and the constant risk of serious infection brought about by the use of immunosuppressant drugs limit survival to approximately 40 to 60 percent five years after surgery. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. conclusion In the 21st century. pulmonary fibrosis. but from the late 1970s bilateral lung transplantation had some striking results. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. survival at one year has been reported at 90 percent. Because transplantation offers the only hope for persons with severe lung disease. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. who may be relatively young.

The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. In many countries. sometimes drastically increasing their ability to infect and cause disease in humans. However. basic knowledge of the viruses that cause the common cold eluded scientists. 224 . Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. Influenza viruses circulate globally.7 The Respiratory System 7 respiratory system. 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. and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. which are the most frequent cause of the common cold. The negative influence of behaviours such as tobacco smoking on lung function is now well documented. with health and environmental concerns at the forefront. Such progress promises to reduce the global mortality of lung cancer. mesothelioma. and similar preventable respiratory afflictions. In fact. For decades. acquiring genetic mutations that alter their infectious characteristics. in 2009 researchers reported having mapped the genetic codes of rhinoviruses.

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. 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. In addition. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. as well as new treatments.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. 225 . such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease.

extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. Act on the larynx as a whole. during the act of swallowing. leaf-shaped flap. 226 . glottis A sagittal slit formed by the vocal cords. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. hypercapnia Excess carbon dioxide retention. functions as a lid to the larynx and. convection The transfer of heat by movement of a heated fluid such as air or water. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. epiglottis Cartilaginous. glycolysis Fermentation. moving it upward or downward. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape.GLOSSARY apnea Cessation of breathing. hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. Also known as a decompression chamber or recompression chamber. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. controls the traffic of air and food. or transformation of glucose into energy.

length. metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. a thin membranous sac encasing each lung. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. reduces its surface tension. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. neuraminidase A glycoprotein on the surface of influenza viruses. paranasal sinuses Cavities in the bones that adjoin the nose. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. rhinitis Inflammation of the mucous tissue of the nose. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx.7 Glossary 7 hypoxia Reduction of oxygen supply to tissues to less than physiological levels. and as the organ of phonation. surfactant Substance that. resulting in the development of secondary tumours. pleura In humans. 227 . intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. and tension of the vocal cords. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. purulent Pus-producing. thereby increasing its spreading and wetting properties. when added to a liquid.

Control of breathing is described in Murray D. (1995). Sullivan (eds. Fraser et al. and Robert G. HighAltitude Medicine and Pathology. Bates. H. Pack (eds. Abnormal breathing during sleep is covered by Nicholas A.).BIBLIOGRAPHY Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. a detailed text on impairment of lung function caused by disease. and Michael P. 2nd ed. Physiology of Respiration. (1993). Altose and Yoshikazu Kawakami (eds. ed. Corwin Hinshaw and John F. Hlastala and Albert J. Christie. Fishman and Jack A. The Respiratory System (2003). 4 vol. (1977–79). (1994). Saunders and Colin E.. (1995).).. 2nd ed.). and Ronald V. Dempsey and Allan I. The Physiology and Medicine of Diving. Elliott (eds. 228 . 4th ed. 2nd ed. (2008). Sleep and Breathing. 2nd ed. and Jerome A. 1 also available in a 3rd ed. 2nd. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung.). Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. Elias. (1971). 4th ed. Murray. (2001). Bennett and David H. The effects of swimming and diving on respiration are detailed in Peter B. (1988). Peter T. with vol. The human respiratory system is described in David V. Diagnosis of Diseases of the Chest. Macklem. Fishman’s Pulmonary Diseases and Disorders. Berger. Control of Breathing in Health and Disease (1999). Regulation of Breathing. 4th ed.

Disorders of the Respiratory System. See also John F. Murray and Jay A. (1998). Steven E. (1980). Respiratory Disorders (1983). (1981). provides a comprehensive overview of pathophysiology as related to clinical syndromes. see also J. 2nd ed. Principles of Pulmonary Medicine. Thurlbeck’s Pathology of the Lung.). 2nd ed. 3rd ed. (1994).). Comprehensive texts include Gordon Cumming and Stephen J. is a general textbook covering diagnosis and treatment of chest diseases. 2nd ed. Pulmonary Diseases and Disorders. and Ian R. John Crofton and Andrew Douglas. (2005). Textbook of Respiratory Medicine. G. 4th ed.7 Bibliography 7 Diseases of the Chest.).. and Andrew M. Semple. (1980). 229 . Nadel (eds. Scadding and Gordon Cumming (eds. (1988). Alfred P. Bateman.). 3 vol. Churg et al. Respiratory Diseases. Cameron and Nigel T. Weinberger. (eds. Scientific Foundations of Respiratory Medicine (1981). 3rd ed. Fishman (ed. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. 3rd ed.

217 bronchoscopy. 112–113. 175. 218–220 asbestos. 221 asbestosis. 176. 172. 79–80. 131–133. 97. 171 AIDS. structure and function of. 152–156. 129. 198. 51. 188 bird fancier’s lung. 213 atelectasis. 152. 153. 123. 188–189 alveoli. 111. 184 Actinomyces. 189–192. 111. 111 Adam’s apple. 30. 187 byssinosis. 211. 75. 174 Buerger disease. 171–173. 118–119 air–blood barrier. 170–171 Bordet. 113 alkalosis. 127. 109. 171. 174–175 C cancer. 164. 77 Agricola. 168. 99–100. 94. 73. 50 Breuer. 184. 46. 76. 75 acidosis. 64. 96. 134. 166 black lung. 168–169.INDEX A acid–base balance. 33–34 bronchiolitis. 169. 107. 175. 137. 136. 106 bradykinin. 159. 35. 181. 147. 108. 81. 171 antibiotics. 85 artificial respiration. 52. 169. 211. 159. 103. 86. 197. 223 bronchitis. structure and function of. 196. 230 . 117. 171–173 asphyxiation. 38. 217 Bert. 122. 193 anthracosis. 131. 173. 126 arterial gas embolism. 141–144 B barotrauma. 169. 46. Jules. 33–34 stem. 110. 91. 208. 39 alcoholism. 184–186 altitude sickness. 115. 127. 182. 160–164. structure of. 187 anesthesia. 210. 212–214 aortic body.130–131. Paul. 49 bronchi. 74. Josef. 27 adenosine triphosphate (ATP). 137. 135. Georgius. 81. 205–208 brown lung. 114. 214 antihistamines. 34–35 amantadine. 93. 209 animals. 30. 103 anemia. 48 apnea. 116. 30. 194 asthma. 197 bronchopulmonary dysplasia. 186. 42. 169 lung. 100–102. 52. 28–29 bronchiectasis. 102. 124–125. 152. 198 bronchioles. 92. structure of.

65. 198. 30 Goodpasture syndrome. 196. 91. 182. 159. 98. 137. 197–198 H Haldane. 85. 98. 201 F farmer’s lung. 88–91. 207 physiology of. 117. 161. 98–99 epinephrine. 47. 149. 69. 94. 213 cause of. 87. 192. 95. 47. 188–189. 92. 136–138. 196–197. 160 HIV. 151 D decompression sickness. 214 diving. 106. 183. 80. common. 25. 221. 84. Ewald. 52 chloride shift. 119 231 . 98–99 cystic fibrosis. 197. 65. 62. 80. 50. 136. 215. 84. 81. 182 G gas exchange. 49 high altitudes. 81 central nervous system disease. 108. 211. 187. 48. 137. 67 chronic obstructive pulmonary disease (COPD). 166 fungi. 95. 223 eosinophilic granuloma. 98. 223 7 E emphysema. 58–59. 102. 81–86. 66. 64. 187. 186. 133–136. 168. 63. 189–192. 156. abnormal. 86. 111. 157–158. 190 histamine. 106. 49 Hering-Breuer reflex. 60. 112. 183 hay fever. 94. 222 decongestants. 191–193 drowning. 150 epiglottis. 175. 215. John Scott. 193–195. 210. 218 dyspnea. 199. 34 cold. 137. 97. 50. 78. 145–148. 183.7 Index 181. 212 exercise (training). 87. 122. 96. 197. 51–52. 132. 145. 177. 158. 72 diphtheria. 30. 143. 147. 44. 132 types of. 115. 75. 164. 25. 56. 156–158. Octave. 159. 190. 220. 201. 190. 105–106. 98–99 epiglottitis. 138. 221 cardiopulmonary resuscitation (CPR). 180. 174. 170. 21. 198 croup. 158 diffusion limitation. 164 coughing blood. 106 glycolysis. 93. 52 Cheyne-Stokes breathing. 209. 131. 79–81. 144. 122. 135. 130. 184. 171. 130. 129. 75–78. 69–72 Gengou. 127–129. 122. 211–212 diaphragm. 74 goblet cells. 50. 64. 130. 78. 213 hemoglobin. 67. 215 carotid body. 46. 27. 47. 216–217 Hering. 88 corticosteroids. 204. 217 Clara cells.

186–188 I idiopathic pulmonary fibrosis. 70. 50 meningitis. 149. 135–136. 221–222 hypercapnia. 93. 83. 47. 122. 94. 81 mountain sickness. 125 hypoventilation. 81–82. 96. 144–145. 31 transplantation of. 99. 127 hygiene. 55–56. 172. 92. 103. 171–173. 81 aerobic. 127. 150. 98. 145 K kidney. 50. 88. 38–40 infarction. 138. 221 metabolism. 149. 110. 208 medulla. 52. 147. 94 nerves laryngeal. 117. 204. 149 influenza. 138. 143. 51–52. 152–156. 81 mucoviscidosis. 46–48. 117 mesothelioma. 26 232 . René-ThéophileHyacinthe. 83 hypersensitivity pneumonitis. 99 mediastinoscopy. 44. 26. 166–167 hyperventilation. 68. 156–158. 215. 198. 178. 127. 223 lung ventilation/perfusion scan. 128. 87. 198. 126 hypoxemia. 104 vaccine. 138–141. 167. 87. 74. 45. 190. 151. 182. 113–114. 208–209 mediastinum. 173 cancer of. 173. 114. 110. 184–186 hypothyroidism. 76 Monge disease. 214 leukemia. 184 L Laënnec. 73–78. 177 size of. 129. 215. 176. 181. 199. 41. 221 collapse of. 163 hydrothorax. 141. 217 hypoxia. 114–115. 169. structure and function of. 78 anaerobic. 31.7 The Respiratory System 7 hookworm. 159 congestion of. 139. 209. 37. 199 bird flu. 26–28 Legionnaire disease. 119 hyperbaric chamber. 196 laryngitis. 178. 100 lungs N nephritis. 38. 173. 103 H1N1. 49. 91. 95–96 larynx. 74. 197 development of. 102–105. 76–77. 69. 204–205 M measles.

220 pneumothorax. 85 nose cilia. 21–24. 170. 52–53. 88. 127. 92–94. 114. 88 rimantadine. 87. 118 prostaglandins. 92.Wilhelm Conrad. 103. 136 233 . 220 pleurisy. 105–106. 56. 100 rhinoviruses. 126 pleura. 127–129. 50 psittacosis. 85. 95 shunting. 110 pulmonary alveolar proteinosis. 139. 128. 223 scarlet fever. 23–24 sinus. 125. 107. 34 pyothorax. 214–218 128. 187 rheumatic fever. 179–180 Reynaud disease. 92. 93.7 olfactory. 57. 189. 137. 107. 108. 208. 93 congestion of. 104 osteoporosis. 108–113. 53. 141. 184. 33. 31–32. 154. 150–151 pulmonary edema. 89 structure and function of. 160 sleep. 50 nitrogen narcosis. 208. 24–25 pickwickian syndrome. 107–108. 173. 104–105 respiratory distress syndrome. 198. 45. 22 irrigation of. 122. 211. 87. 108. 91. 124. 209. 19. 91. 126–130. 221 pollution. 99 Index 7 O obesity. 95. 128 R Relenza. 22. 41. 47 vagus. 129–130. 198 pleural effusion. 113. 170 pneumonia. 138. 214 pertussis. 200. structure and function of. 137 oxygen therapy. 214. 94. 93 sinusitis. 168–169. 127. 26. 146. 103. 117. 126 oseltamivir. 180–182 pons. 114 Pott disease. 91–92. 152. 178. 159. 106. 38. 149–150. 33. 198. 180. 211. 36. 103 Röntgen. 107 penicillin. 139. 155. 169–170 sinuses. 172. 126. 44 Pontiac fever. 87. 131. 164 pharyngitis. S sarcoidosis. 69–71 silicosis. 167. 214 pharynx. 203 P parasites. 194 pulmonary parenchyma. 50. 198 pneumoconiosis. 179 rheumatoid arthritis. 122 function of. 126. 91. 84. 130. 103. 111 parrot fever. 164 inflammation of. 136.

170. 108. 27–28 T Tamiflu. 153. 53. 109. 124 W whooping cough. 87. 150. 164. 56. 91. 96–98 trench mouth. structure and function of. 99. 129. 122. 138. 106. 209 swimming. 95. 97 smell. 92 streptococcal bacteria. 171. 220–221 thoracic emphyema. 97. 116. 128. 92. 33. 110. 97. 214 surgery. 133–135. 94 staphylococci.102. 99. 28–30 tracheitis. 123–124 sore throat. 178. 172. 23–24. 87. 136. 105–107 Z zanamivir. 199. 88. 204. 127–129 thoracic squeeze. 21. 163. 104 tetanus. 97 V vaccination. 95. 137. 138. 103. 87. 96. 164 snoring. 152. 119.7 The Respiratory System 7 smallpox. 94–95. 146 strep throat. 94–95 tonsils. 111. 91 vocal chords. 192–193 tonsillitis. 92. 220 typhoid. 106 thoracentesis. 92. 69 vestibular folds. 94. 97 trachea. 143. 25. 164. 93. 218 sneezing. 95. 92. 103. 58 ventilation–blood flow imbalance. 138. false. 102. 130. 176. 125. 53. 96. 171. 103. 118. 95 tuberculosis. 130. 197. 199. 81–86 syphilis. 91. 182. 93. 175. 104–105 234 . 122. 183. 123. 97. 198. 92. 97. 94 smoking. 78. 173 Valsalva maneuver. 131–132. 114–121. 91. 208. 107. 155–156. 27–28 vitamin C.

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