Kara. Inc. Production Control Steven Bosco: Director. Copyright © 2011 Encyclopædia Britannica. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. 87. New York. 196.2—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. Media Acquisition Kara Rogers: Senior Editor. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. All rights reserved. All rights reserved.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. and the Thistle logo are registered trademarks of Encyclopædia Britannica. Rosen Educational Services. 159. Britannica. Rogers. NY 10010. For a listing of additional Britannica Educational Publishing titles. © www.com / nicoolay . LLC 29 East 21st Street. -.” Includes bibliographical references and index.) in association with Rosen Educational Services.E. Editorial Technologies Lisa S. Inc. Inc. ISBN 978-1-61530-147-8 (library binding) 1. 60. I. Chip Somodevilla/Getty Images On pages 19. QP121. Levy: Executive Editor J. p.istockphoto. cm. First Edition Britannica Educational Publishing Michael I. 41. Biomedical Sciences Rosen Educational Services Heather M. Rosen Educational Services materials copyright © 2011 Rosen Educational Services.istockphoto. call toll free (800) 237-9932. © www. 230: A healthy set of lungs is the powerhouse behind the respiratory system. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers.(The human body) “In association with Britannica Educational Publishing. Distributed exclusively by Rosen Educational Services. Barton: Senior Coordinator. 228. Respiratory organs—Popular works.R467 2011 612. 122. Luebering: Senior Manager Marilyn L. LLC. Encyclopædia Britannica. 226.

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

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 . Circulation.61 The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This portion of the chest membrane is called the parietal pleura. The laryngeal skeleton consists of almost a dozen pieces of cartilage. as the mediastinal pleura. Sound is produced by forcing air through a sagittal slit formed by the vocal cords. The largest cartilage of the larynx. The chest cavity is lined with a serous membrane. when it occurs. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. interconnected by ligaments and membranes. the muscles must be anchored to a stabilizing framework. and as the organ of phonation. and the great vessels. the two surfaces tend to touch. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. the thyroid cartilage. the glottis. As evidenced by trained singers. the mediastinum being the space and the tissues and structures between the two lungs. This causes not only the vocal cords but also the column of air above them to vibrate. between the parietal and the visceral pleura. the heart. and over part of the esophagus.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. The membrane continues over the lung. For the precise function of the muscular apparatus. or serum. 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. is made of two plates fused 26 . this function can be closely controlled and finely tuned. where it is called the visceral pleura. so called because it exudes a thin fluid. most of them minute. Control is achieved by a number of muscles innervated by the laryngeal nerves. The pleural cavity is the space.

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

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

The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. however. largely determines the internal lung structure. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. however. purely conducting zone. From a morphological point of view. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. if the trachea is counted as generation zero. where both functions grade into one another. however. and partly also of the blood vessels penetrating the lung. In irregular dichotomy. the daughter branches may differ greatly in length and diameter. structural design of the airway tree The hierarchy of the dividing airways. a peripheral. it is generally agreed that the airways branch according to the rules of irregular dichotomy. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. The structure of the stem bronchi closely matches that of the trachea. and a transitional zone in between. may range from 11 to 30 generations. 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. purely gas-exchanging zone. In modeling the human airway tree. it makes sense to distinguish the relatively thick-walled. Individual paths. 29 . the intrapulmonary airway system can be subdivided into three zones: a proximal.

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

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

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

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

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

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

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

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


The Respiratory System


paths from the lung are complex. The precise knowledge of their course is clinically relevant, because malignant tumours of the lung spread via the lymphatics. The pleurae, the airways, and the vessels are innervated by afferent and efferent fibres of the autonomic nervous system. Parasympathetic nerve fibres from the vagus nerve (10th cranial nerve) and sympathetic branches of the sympathetic nerve trunk meet around the stem bronchi to form the pulmonary autonomic nerve plexus, which penetrates into the lung along the bronchial and vascular walls. The sympathetic fibres mediate a vasoconstrictive action in the pulmonary vascular bed and a secretomotor activity in the bronchial glands. The parasympathetic fibres stimulate bronchial constriction. Afferent fibres to the vagus nerve transmit information from stretch receptors, and those to the sympathetic centres carry sensory information (e.g., pain) from the bronchial mucosa.

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

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

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

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

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

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

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

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

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

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

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

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. 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.7 The Respiratory System 7 The brain also seems to anticipate changes in the metabolic rate caused by exercise. body metabolism is reduced. however. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. 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. This rhythmic waxing and waning of breathing. how these various mechanisms are adjusted to maintain acid–base balance. The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. breathing can become quite erratic. It remains unclear. with intermittent periods of apnea. 52 . is called Cheyne-Stokes breathing. after the physicians who first described it. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. breathing is diminished but remains regular. or even apnea (cessation of breathing). because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. In slow-wave sleep. The effects on ventilatory pattern vary with sleep stage. During sleep. but it may entail unstable feedback regulation of breathing. whereas in rapid eye movement sleep.

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

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

of the force required to keep the lung distended. This. The pressure measured in the small pleural space so created is substantially below atmospheric pressure at a time when the pressure within the lung itself equals atmospheric pressure. In summary. 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. lung air becomes transiently compressed. therefore. then. 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. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. This negative (below-atmospheric) pressure is a measure.7 Control and Mechanics of Breathing 7 decreases. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. This tendency of the lung to collapse or pull away from the chest is measurable by carefully placing a blunt needle between the outside of the lung and the inside of the chest wall. The Lung–Chest System The forces that normally cause changes in volume of the chest and lungs stem not only from muscle contraction but from the elastic properties of both the lung and the chest. its pressure rises above atmospheric pressure. the pleural pressure reflects primarily two forces: 55 . tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. thereby allowing the lung to separate from the chest at this particular spot.

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

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. Pressures 57 .154 cubic inches) per minute in adults. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). The respiratory pump is versatile. The volume in these circumstances is known as the residual volume. capable of increasing its output 25 times. 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. expiration being accomplished “passively” by elastic recoil of the lung. muscular contraction occurs only on inspiration. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. At total relaxation of the muscles of inspiration and expiration. separated by a film of water. During ordinary breathing. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. such as pieces of glass. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen.

The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles.e.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. can be raised voluntarily to 400 litres per minute.. with no space between the vocal cords). Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.istockphoto.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. The beating of cilia (hairline projections) from cells lining the airways 58 . normally reaching 30 litres per minute in quiet breathing.7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. Airflow velocity. © www .

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

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

Shutterstock.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.

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

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

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

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

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

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

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

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. 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. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. This abnormality leads to parallel changes in both gas and blood and is the only abnormality in gas exchange that does not cause an increase in the normally small difference between arterial and alveolar partial pressures of oxygen. but the level of carbon dioxide in arterial blood is not elevated even 69 . shunting. 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. A reduction in arterial blood oxygenation is seen with shunting. ventilation– blood flow imbalance. and limitations of diffusion. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition.. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. In shunting. alveoli filled with fluid or inflammatory material). Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. Because of the differences in oxygen and carbon dioxide transport. venous blood enters the bloodstream without passing through functioning lung tissue.g.

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

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

These factors are usually grouped under the broad description of “diffusion limitation. Carbon dioxide exchange. In healthy lungs there is a narrow distribution of the ratio of ventilation to blood flow throughout the lung that is centred around a ratio of 1 to 1.7 The Respiratory System 7 alveolar partial pressure of oxygen. which facilitates carbon dioxide exchange. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. 72 . loss of surface area available for diffusion of oxygen. these include increased thickness of the alveolar–capillary membrane. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. a reduction in the alveolar partial pressure of oxygen required for diffusion. and decreased time available for exchange due to increased velocity of flow. A variety of processes can interfere with this orderly exchange. In disease. and increased ventilation will not increase blood oxygen content. the greater the reduction in blood oxygenation. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. For oxygen. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. is not affected by an abnormal ratio of ventilation and blood flow as long as the increase in ventilation that is required to maintain carbon dioxide excretion in overventilated alveoli can be achieved. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. however.

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

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

or. transport by blood flow. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. which is carried by both plasma and red blood cells and which also serves as a buffer for acid–base balance in blood and tissues. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. essentially resulting from a higher heart rate. which is achieved by convection or mass flow of air through an ingeniously branched system of airways.7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. which is determined by its content of hemoglobin in the red blood cells. At rest. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. This is accompanied by an increased cardiac output. and carbon dioxide. which is bound to hemoglobin in the red blood cells. but a highly trained athlete may achieve a more than 20-fold increase. sets the demand for oxygen. a human consumes about 250 ml of oxygen each minute. With exercise this rate can be increased more than 10-fold in a normal healthy individual. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. Metabolism. the demand for ATP and oxygen increases linearly with work rate. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. Blood also serves as carrier for both respiratory gases: oxygen. more accurately the metabolic rate of the cells.5 micrometre) and the surface area of the barrier. As more and more muscle cells become engaged in doing work. and by 75 . Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. In the most peripheral airways. and discharge to the cells.

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

Mitochondria set the demand for oxygen. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system. in all types of variation. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. cardiac output is augmented by increasing heart rate. This difference arises from a phenomenon known as adaptive variation. For example. If energy (ATP) needs to be produced at a higher rate. 77 .com Within the aerobic scope the adjustments are caused by functional variation. Shutterstock. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. the muscle cells make more mitochondria. the mitochondria increase in proportion to the augmented aerobic scope. In training.7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals.

whereas the mitochondria. 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. rate. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. 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 lung may well constitute the ultimate limit for the respiratory system. both in terms of rate and of the size of the ventricles. beyond which oxidative metabolism cannot be increased by training. The issue of peripheral versus central limitation is still under debate. If this proves true. however. or volume to augment their capacity when energy needs increase. the lung lacks this capacity to adapt. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. the blood.7 The Respiratory System 7 It is thus possible that oxygen consumption is limited at the periphery. 78 . whose capacity to pump blood reaches a limit. mainly the heart. such as in training. But. and the heart can increase in number. the structure of the alveoli in the lungs. In the cases of swimming and diving. It appears. the blood vessels. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. In the case of adaptation to high altitudes. at the last step of aerobic metabolism. the levels of hemoglobin in the blood. which determines the volume of blood that can be pumped with each stroke.

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

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

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

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

the blood and tissues of the diver. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. rather than cardiac or muscular performance. the levels of inspired oxygen are 83 . Alveolar oxygen levels can also be disturbed in diving. is the vertical hydrostatic pressure gradient across the body. The increased work of breathing. Hypoxia may result from failure of the gas supply and may occur without warning. often with the formation of bubbles.7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. acting at any depth. and their subsequent elimination from. is the limiting factor for hard physical work underwater. the increased density of the respiratory gases. is one factor. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). This may be compounded by an increased inspiratory content of carbon dioxide. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. The effects of pressure are seen in many processes at the molecular and cellular level and include the physiological effects of the increased partial pressures of the respiratory gases. The other factor. More commonly. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. The multiple effects of submersion upon respiration are not easily separated from one another or clearly distinguishable from related effects of pressure upon other bodily systems. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. and the consequences of the uptake of respiratory gases into.

and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. 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.5 bar (“surface equivalent value” = 150 percent). like an anesthetic.7 The Respiratory System 7 increased. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. At the extreme depths now attainable by humans— some 500 metres (1. The use of hydrogen.5 bar. Oxygen in excess can be a poison. approximately in proportion to the reciprocal of the square root of the increasing gas 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.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. has the additional advantage of providing a breathing gas of lesser density.640 feet) in the sea and more than 680 metres (2. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. In mixed-gas diving. which in a mixture with less than 4 percent oxygen is noncombustible. provides a greater respiratory advantage for deep diving. At a partial pressure greater than 1. High values of end-tidal carbon dioxide with 84 .2 and 0. it may cause the rapid onset of convulsions. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner.

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

even from depths as shallow as 2 metres (6. Decompression sickness is caused by the formation of bubbles from gases that were dissolved in the tissues while the diver was at an increased environmental pressure. 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.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. 86 .6 feet). Inadequacy of diver decompression. Other possible causes of pulmonary barotrauma include retention of gas by a diseased portion of lung and gas trapping due to dynamic airway collapse during forced expiration at low lung volumes. can result in a sometimes life-threatening condition known as decompression sickness.

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

Rhinoviruses. sometimes spreads to the lower respiratory structures. or drafts. The feeling was originally believed to have a cause-and-effect relationship with the disease. More than 200 agents can cause symptoms of the common cold.7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses. and may cause secondary infections in the eyes or middle ears. and reoviruses. with little or no medication. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract. however. respiratory syncytial viruses. Some of these infections may resolve on their own. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. The cold is caught from exposure to infected people. and tonsils are frequently the site of both acute and chronic infections. The viruses start spreading from an infected person before the symptoms appear. In other cases. chilled wet feet. not from a cold environment. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. but this is now known to be incorrect. including parainfluenza. influenza. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. pharynx. People can carry the virus and communicate it without experiencing any of the symptoms themselves. and the 88 . however. usually one to four days. an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. Incubation is short. are the most frequent cause.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

pigeons. and another booster is given when the child is between four and six years old. attributed to contact with imported parrots. when severe outbreaks. also known as ornithosis (or parrot fever). Strict regulations followed concerning 107 . 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. ducks. an antibiotic that may help to shorten the duration of illness and the period of communicability. The infection has been found in about 70 different species of birds. parrots and parakeets (family Psittacidae.7 Infectious Diseases of the Respiratory System 7 protection. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. Later vaccinations are in any case thought to be unnecessary. and sometimes the use of an oxygen tent is required to ease breathing. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. and geese are the principal sources of human infection. turkeys. Treatment includes erythromycin. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. occurred in 12 countries of Europe and America. Sedatives may be administered to induce rest and sleep. England. the causative agent was revealed. Psittacosis Psittacosis. from which the disease is named). The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. especially if they have been vaccinated in infancy. 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.

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

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

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

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

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

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

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

tuberculosis remains a major fatal disease. 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. In addition. in less-developed countries where population is dense and hygienic standards poor. Fox Photos/Hulton Archive/Getty Images 1940s. antibiotic drugs have reduced the span of treatment to months instead of years. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. but in areas with poor hygiene standards. the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 . 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.

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

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

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

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

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

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

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

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

Obstructive sleep apnea is most often caused by excessive fat in the neck area. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. the condition has a strong association with certain measures of obesity. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. In men shirt size is a useful predictor. Children’s snoring usually results from enlarged tonsils or adenoids. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. meaning “without breath. or body-mass index. body weight. Whatever the cause. with the likelihood of OSA increasing 124 . 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. at which point the airway reopens and the person resumes breathing. airway collapse is eventually terminated by a brief awakening. and it occurs most often in obese persons. which is the most common form and involves the collapse of tissues of the upper airway. The word apnea is derived from the Greek apnoia. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. Thus. such as neck size. In obstructive sleep apnea (OSA). which involves characteristics of both obstructive and central apneas. and mixed. central.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx. In addition.” There are three types of sleep apnea: obstructive. Loud interrupted snoring is a regular feature of sleep apnea. a common and potentially lifethreatening condition that generally requires treatment. It is also more common in men than in women.

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

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

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

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

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

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

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

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

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

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

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

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

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

after reinflation of a collapsed lung. Excessive irradiation and severe allergic reactions may also produce this disorder. A person with pulmonary edema experiences difficulty in breathing. 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. Acute cases can be fatal in 10 to 20 minutes. After an operation. either partially or fully. for unknown reasons. It can occur.7 Diseases and Disorders of the Respiratory System 7 mechanical edema the capillary permeability is broken down by the same type of heart disorders and irritants as in congestion. if too great a volume of intravenous fluids is given. with deep gurgling rattles in the throat. because he or she is too weak to clear the fluids. and heavy. The term is derived from the Greek words atele s and ektasis. because of specific respiratory disorders. and obstructive. This is typically caused by a failure to develop surface-active material 141 . the blood pressure rises and edema ensues. The person’s skin turns blue. compressive. It may take only one or two hours for two to three quarts of liquid to accumulate. their lungs show areas in which the alveoli. literally meaning “incomplete expansion” ¯ in reference to the lungs. The lungs become pale. the person may actually drown in the lung secretions. There are three major types of atelectasis: adhesive. The term atelectasis can also be used to describe the collapse of a previously inflated lung. wet. These infants usually suffer from a disorder called respiratory distress syndrome. or air sacs. are not expanded with air. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed. and.

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

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

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

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

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

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

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

or granulomas. Sharp crackling sounds. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. The disease most commonly manifests between ages 50 and 70. Some individuals have clubbed fingertips and toes. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. some people live 10 years or longer. Some individuals may benefit from single or double lung transplantation.7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. In addition. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. however.” are heard through a stethoscope applied to the back in the area of the lungs. The average duration of survival from diagnosis is four to six years. A dry cough is common as well. there is no effective treatment. in different organs. Other common changes are enlargement of the lymph 149 . Aside from administration of supplemental oxygen. called rales or “Velcro crackles. the lung is commonly involved. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs. with insidious onset of shortness of breath on exertion. pulmonary function testing shows a reduction in lung volume.

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

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

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

smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. and roofers. In countries with a prolonged history of cigarette smoking. and workers exposed to halogenated ethers also have an increased incidence. tar refiners. small-cell 153 . welders. Of the two basic forms. In cases where the cancer has spread beyond the lungs. such as coal processors. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. a persistent cough or wheeze. Tumours can begin anywhere in the lung. Uranium and pitchblende miners. Heavy smokers have a greater likelihood of developing the disease than do light smokers. as do some workers in hydrocarbon-related processing. The risk is also greater for those who started smoking at a young age. secondhand smoke accounts for an estimated 3. Other risk factors include exposure to radon gas and asbestos. unexplained weight loss. chromium and nickel refiners. and susceptibility to lower respiratory infections. between 80 and 90 percent of all cases are caused by smoking. or bone pain may occur. the tumour’s type and degree of invasiveness are determined.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. Lung cancer is rarely caused directly by inherited mutations. Types of Lung Cancer Once diagnosed.400 deaths from lung cancer in nonsmoking adults in the United States each year. visible lumps. The most common symptoms include shortness of breath. According to the American Cancer Society. chest pain. jaundice. bloody sputum.

adenocarcinoma. 154 . and both lungs or metastasis to other organs. It is characterized by cells that are small and round. Cancer cells may be detected in sputum. or shaped like oat grains. and Prevention Lung cancers are often discovered during examinations for other conditions. Small-cell carcinoma (SCLC).7 The Respiratory System 7 carcinoma accounts for 20 to 25 percent of all cases and non-small-cell carcinoma is responsible for the remainder. is rarely found in people who have never smoked. also called oat-cell carcinoma. also called epidermoid carcinomas. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. but it is the most common type of lung cancer in the United States. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. and it often develops in the larger bronchi of the central portion of the lungs. 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. Diagnosis. Cells of adenocarcinoma are cube. peripheral bronchi. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. and large-cell carcinoma. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. oval. the survival rate is very low. About 10 percent of all lung cancers are large-cell carcinomas. This tumour is characterized by flat. Tumours often originate in the smaller. Treatment. SCLC is the most aggressive type of lung cancer. Because it tends to spread quickly before symptoms become apparent. scalelike cells. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. pleura.or column-shaped. and they form structures that resemble glands and are sometimes hollow.

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

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

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

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

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

In addition. stress may exacerbate symptoms. and. dust mites. such as chemicals. coughing. Adults who develop asthma may also have chronic rhinitis. and breathlessness that range in severity from mild to life-threatening.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. 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. such as pollen. that may induce an allergic reaction. and grains. boys being affected more often than girls. These substances provoke both allergic and nonallergic forms of the disease. which may be involved in any general inflammatory response. Adult asthma is sometimes linked to exposure to certain materials in the workplace. the lung contains a very large vascular bed. aspirin. asthma may develop in response to allergens. 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. In adults. In 160 . Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. When asthma develops in childhood. and exercise may cause it as well. or animal dander. chest tightness. it is often associated with an inherited susceptibility to allergens— substances. but viral infections. nasal polyps. Although an initial episode can occur at any age. however. Asthmatic episodes may begin suddenly or may take days to develop. causing episodes of wheezing. weather conditions. approximately half of all cases occur in persons younger than age 10. third. The most common and most important of these is asthma. or sinusitis. wood dusts. second. women are affected more often than men.

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

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

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

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

Broman—Root Resources 165 . Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Giant ragweed (Ambrosia trifida) is a common cause of hay fever. Louise K.

This causes an acute febrile illness with a characteristically fine opacification (clouding. with shortness of breath persisting after the radiographic changes have disappeared. and in France. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). after 166 . or becoming opaque) in the basal regions of the lung on the chest radiograph. these represent different kinds of allergic responses to proteins from birds. Farmer’s lung is common in Wisconsin. and canaries. granulomas. One of these illnesses is the so-called farmer’s lung.7 The Respiratory System 7 Hypersensitivity Pneumonitis Hypersensitivity pneumonitis is an important group of conditions in which the lung is sensitized by contact with a variety of agents and in which the response to reexposure consists of an acute pneumonitis. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. A similar group of diseases occurs in those with close contact with birds. in the west of England. with inflammation of the smaller bronchioles. or aggregations of giant cells. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. and there may be measurable interference with diffusion of gases across the alveolar wall. Airflow obstruction in small airways is present. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. particularly proteins contained in the excreta of pigeons. Variously known as pigeon breeder’s lung or bird fancier’s lung. the condition may become chronic. may be found in the lung. If untreated. on the eastern seaboard of Canada. alveolar wall edema. budgerigars (parakeets). In more chronic forms of the condition.

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

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

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

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

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

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

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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


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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.

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

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

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

aspiration of material into the lung (including water in near-drowning episodes). widespread bilateral lung injury. although superimposed infection or multiple organ failure can result in death. 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. exposure of the lung to gases.000 people during that week and the subsequent three weeks. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. Acute respiratory distress syndrome carries about a 50 percent mortality rate. but not all. Most children who survive have no aftereffects. Life-support treatment with assisted ventilation rescues many patients. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. 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 4.7 The Respiratory System 7 blood and removing carbon dioxide. which had been intermittently considered since the 14th century 180 . Prize cattle at an agricultural show also died in the same period as a result of the air pollution. In adults. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. Many. This syndrome is known as acute respiratory distress syndrome of adults. Many causes of respiratory distress syndrome of adults have been identified. This episode spurred renewed attention to this problem. 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. bacterial or viral pneumonia.

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

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

A 4 percent increase in the blood carbon monoxide level in patients with coronary artery disease is believed to shorten the duration of exercise that may be taken before chest pain is felt. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. a condition in which hemoglobin is deficient. Judgment is also impaired. Carbon monoxide is produced by incomplete combustion. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. 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. including combustion of gas in automobile engines. For this reason. leaving only 60 percent available to bind to oxygen).7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. 183 . 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. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). as part of his detailed analysis of atmospheres in underground mines. 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.

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

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

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

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

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

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. and may even become unconscious. having no measurable vital signs—heartbeat.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The predominant symptom felt by the diver is pain when the pressure becomes too great. but eventually it ceases. Until recently.300 feet). usually water. 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. more than 10 times the depth that humans can tolerate. Any symptoms of thoracic squeeze call for prompt medical attention. There the heart may continue to beat feebly for a brief interval. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. their lungs. the diver may have difficulty in breathing. Drowning Drowning is suffocation by immersion in a liquid. and gives up the remaining tidal air in his or her lungs. physically and intellectually. even when reduced.000 metres (3. These aquatic mammals have been found to have more elastic chest cavities than humans. loses consciousness. and their bodies are adapted to use the gases in the bloodstream more conservatively. do not separate from the chest wall. It is now known that victims immersed for an hour or longer may be totally salvageable. A fuller appreciation of the 193 . may exhale frothy blood. pulse. If the thoracic squeeze has been sufficient to cause lung damage. Deprived of oxygen the victim stops struggling. The sperm whale is reported to dive to about 1. or breathing—at the time of rescue. Artificial respiration may be necessary if the breathing has stopped. although they lack evidence of life. which can be relieved by ascending.

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

Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. 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.” “Lifeless” immersion victims with core temperatures as low as 62. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia.6 °F (17 °C) have survived. 195 . slows the heart rate. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. and promotes unconsciousness. survival following hypothermic coma is almost 75 percent.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. Such warmwater drownings occur commonly in domestic bathtubs.

many technological advances. Today. In addition. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. A cough productive of sputum is the most important manifestation of inflammatory or 196 . One of the most important advances in the history of respiratory medicine was the development of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. or respiratory medicine.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. This expansion of scientific understanding has enabled important progress in respiratory medicine. Likewise. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. have contributed to improvements in the diagnosis and evaluation of respiratory disease. especially in the area of disease prevention. particularly concerning techniques employing X-ray imaging or endoscopy. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. physiology. and pathology of the human respiratory system is known as pulmonology. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few.

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

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

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

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

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

7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs). and (2) those measuring respiratory function. 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. or the transfer of gas between the alveoli and the blood. Tests of ventilatory function include the following measurements: residual 202 . There are two general categories of pulmonary function tests: (1) those that measure ventilatory function.

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

Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. This approach may be taken for patients with advanced or rapidly spreading lung cancer. unfortunately. 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. thereby narrowing the passageway and hindering the flow of blood. this technique is of little value in screening for lung cancer because the stage at which the disease is detectable by this method is too far advanced for treatment to be of value. or VQ (ventilation quotient) scan.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. but. the blockage of one of the pulmonary arteries or of a connecting vessel. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. For the perfusion part of the scan. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 . 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. To track the movement of air.

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

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

they remain superior for specific applications. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. 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. both flexible and rigid scopes have a channel through which instruments can be passed. 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. Bronchoscopy is also employed to remove foreign objects from the airways.. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. blood) to be removed during an examination. to deliver certain therapeutic agents directly into the lungs. 207 .7 Approaches to Respiratory Evaluation and Treatment 7 cough or who are coughing up blood. There are two types of bronchoscopes. because of their ability to bend and twist. In addition. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways.g. Flexible scopes. and to assist in the placement of stents (tubes. consists of a metal tube that has a wide suction channel. which enables large volumes of fluid (e. The second type of scope. known as a rigid bronchoscope.

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

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

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

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

causing anxiety. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . following its release from certain large cells (mast cells) within the body. any of several species of shrubs of the genus Ephedra. insomnia.7 The Respiratory System 7 division of the autonomic nervous system. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. they must be used repeatedly. which has been used in Chinese medicine for more than 5.000 years. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. Ephedrine and other decongestants are made by chemical synthesis. The oldest and most important decongestant is ephedrine. inflammation. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. in which epinephrine constricts the blood vessels of the skin. One of the chief drugs of the group is epinephrine. amphetamine and several derivatives. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. too frequent use. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. or heart palpitations. headache. Because none of them has a sustained effect. an alkaloid originally obtained from the leaves of ma huang. dizziness. however. and naphazoline hydrochloride. thereby preventing histaminetriggered reactions under such conditions as stress. They include phenylephrine hydrochloride. results in absorption into the bloodstream. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. and allergy.

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

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

In both the hospital and the home settings. 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. home oxygen therapy may be prescribed by a physician. known as hyperbaric oxygen therapy (HBOT). employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. portable compressed-gas oxygen cylinder. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). Some patients may require oxygen administration via a transtracheal catheter. such as chronic obstructive pulmonary disease (COPD). For patients affected by chronic lung diseases. In addition. which is inserted directly into the trachea by way of a hole made surgically in the neck. Another form of therapy. however. In emergency situations. HBOT has been promoted as an alternative therapy for certain conditions. oxygen may be administered by citizen responders via mouth-to-mouth breaths in cardiopulmonary resuscitation (CPR) or by emergency medical personnel via a face mask placed over the victim’s mouth and nose that is attached to a small. The high-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. 215 .7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. a device inserted into the nostrils that is connected by tubing to an oxygen system. oxygen may be delivered through a face mask or through a nasal cannula. These applications are controversial.

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

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

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

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

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

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

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

many people who die of severe head injuries. With proper selection of donor organs and proper transplantation technique. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. Persons severely disabled by cystic fibrosis. 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.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. pulmonary fibrosis. but from the late 1970s bilateral lung transplantation had some striking results. the techniques are being pursued aggressively in specialized centres. conclusion In the 21st century. Because transplantation offers the only hope for persons with severe lung disease. Availability of donor lungs is sharply limited by the number of suitable donors. for example. often have also suffered lung injury or lung infection. sarcoidosis. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. who may be relatively young. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. which presumably would leave the lungs intact. respiratory medicine has continued to fulfill a vital role in advancing scientists’ understanding of respiratory disease and of the basic cellular and molecular processes that contribute to the normal function of the 223 . survival at one year has been reported at 90 percent. emphysema.

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

such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. 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. For example. As researchers and physicians continue to uncover new information about the human respiratory system. 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. 225 . these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. the identification of disease-associated metabolic changes within cells and tissues has played an important role in the development of various functional and diagnostic tests.

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

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

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

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

106 bradykinin. 152–156. 52. 113 alkalosis. 137. 159. 74. 48 apnea. 81. 171–173. 184–186 altitude sickness. 211. 49 bronchi. 173. 171 antibiotics. 175. 214 antihistamines. 46. 93. 197 bronchopulmonary dysplasia. Paul.INDEX A acid–base balance. 169. 169. 115.130–131. 46. 108. Georgius. 211. 168. 181. 221 asbestosis. 111. 137. 116. 212–214 aortic body. 174–175 C cancer. 127. 160–164. 184 Actinomyces. 64. 76. 30. 184. 218–220 asbestos. 30. 170–171 Bordet. 159. 171 AIDS. 33–34 bronchiolitis. 97. 175. 112–113. 189–192. 176. structure and function of. 147. 217 bronchoscopy. 171. 135. 171–173 asphyxiation. 193 anthracosis. 198. 111. 34–35 amantadine. 209 animals. 126 arterial gas embolism. 223 bronchitis. 134. 152. 28–29 bronchiectasis. Josef. 75. 103 anemia. 94. 188–189 alveoli. 118–119 air–blood barrier. 117. 50 Breuer. 79–80. 122. structure of. 205–208 brown lung. 77 Agricola. 188 bird fancier’s lung. 124–125. 172. 51. 102. structure of. 186. 85 artificial respiration. 153. 52. 131. 100–102. 213 atelectasis. structure and function of. 210. 217 Bert. 92. 168–169. 103. 187 anesthesia. 73. 86. 169. 38. 114. 42. 166 black lung. 129. 141–144 B barotrauma. 27 adenosine triphosphate (ATP). 169 lung. 131–133. 39 alcoholism. 164. 197. 35. 187 byssinosis. 109. 230 . 99–100. 123. Jules. 198 bronchioles. 75 acidosis. 81. 107. 96. 127. 30. 196. 91. 174 Buerger disease. 136. 208. 182. 152. 194 asthma. 33–34 stem. 110. 111 Adam’s apple.

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

167. 76–77. 88. 87. 223 lung ventilation/perfusion scan. 182. 208–209 mediastinum. 81 mountain sickness. 126 hypoxemia. 87. 147. 197 development of. 184 L Laënnec. 26–28 Legionnaire disease. 138. 181. 145 K kidney. 98. 91. 26. 141. 51–52. 173. 52. 99. 204. 209. 26 232 . 144–145. 95–96 larynx. 135–136. 94 nerves laryngeal. 38–40 infarction. 68. 150. 215. 221 metabolism. 199 bird flu. 37. 127. 129. 55–56. 102–105. 76 Monge disease. 177 size of. 81–82. 92. 172. 178. 99 mediastinoscopy. 50. 196 laryngitis. 156–158. 125 hypoventilation. 149. 159 congestion of. 31. 94. 176. 166–167 hyperventilation. 199. 127. 114–115. 138. 127 hygiene. 149. 173. 178. 139. 70. 186–188 I idiopathic pulmonary fibrosis. 46–48. 83 hypersensitivity pneumonitis. 81 mucoviscidosis. 221 collapse of. 81 aerobic. 78 anaerobic. 104 vaccine. 38.7 The Respiratory System 7 hookworm. 151. 117 mesothelioma. 198. 100 lungs N nephritis. 50 meningitis. 163 hydrothorax. 83. 214 leukemia. 217 hypoxia. 138–141. 152–156. 128. 190. 110. 93. 171–173. 149 influenza. 49. 117. 113–114. 122. 114. 74. 47. 103 H1N1. 119 hyperbaric chamber. 169. 69. 45. 204–205 M measles. 103. structure and function of. 73–78. 221–222 hypercapnia. 143. 44. 74. 198. 215. 208 medulla. 110. 173 cancer of. 184–186 hypothyroidism. René-ThéophileHyacinthe. 96. 31 transplantation of. 41.

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

122. 136. 208. 95. 23–24. 127–129 thoracic squeeze. 27–28 vitamin C. 125. 130. 25. 164. 150. 155–156. 103. 58 ventilation–blood flow imbalance. 94 smoking. 138. 95. 153. 107. 97. 129. 124 W whooping cough. 97. 192–193 tonsillitis. 91. 81–86 syphilis. 105–107 Z zanamivir. 94–95. 21. 109. 214 surgery. 119. 143. 199. 106 thoracentesis. 146 strep throat. 87. 130. 138. 69 vestibular folds. 220–221 thoracic emphyema. 87. 91. 110. 28–30 tracheitis. 133–135. 171. 95. 96. 111. 104–105 234 . 128. 33. 93. 97 trachea. 164. 97 smell. 53. 199. 94 staphylococci. 103. 122. 93. 27–28 T Tamiflu. 87. 92. 92 streptococcal bacteria. 198. 172. 106. 138. 97. 123–124 sore throat. 176. 94. 183. 175. 91 vocal chords. false. 118. 56. 92. 178. 96–98 trench mouth. 91. 92. 92. 99. 95 tuberculosis. 137. 104 tetanus. 99. 114–121. 103. 116. structure and function of.102. 94–95 tonsils. 152. 88. 96. 102. 209 swimming. 182. 218 sneezing. 78. 220 typhoid. 173 Valsalva maneuver. 170. 204. 92. 97 V vaccination. 197. 131–132. 163. 123. 171. 53. 108. 97.7 The Respiratory System 7 smallpox. 164 snoring.

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