R467 2011 612. LLC. p. QP121. Media Acquisition Kara Rogers: Senior Editor. Luebering: Senior Manager Marilyn L. 60. For a listing of additional Britannica Educational Publishing titles. Kara. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. Barton: Senior Coordinator. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. All rights reserved. cm.) in association with Rosen Educational Services. NY 10010. 41. Encyclopædia Britannica.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. 230: A healthy set of lungs is the powerhouse behind the respiratory system. Levy: Executive Editor J. ISBN 978-1-61530-147-8 (library binding) 1. Inc. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. Respiratory organs—Popular works. Chip Somodevilla/Getty Images On pages 19. and the Thistle logo are registered trademarks of Encyclopædia Britannica. All rights reserved.istockphoto. 228. First Edition Britannica Educational Publishing Michael I.2—dc22 2010014243 Manufactured in the United States of America On the cover: The human lungs are extraordinary organs that constantly pump crucial oxygen through airways and into the bloodstream. -. I. Distributed exclusively by Rosen Educational Services. Production Control Steven Bosco: Director. 122. © www. 196. Biomedical Sciences Rosen Educational Services Heather M. 226.E. © www. Rogers.(The human body) “In association with Britannica Educational Publishing. Inc. Inc. Britannica. 159.com / nicoolay .” Includes bibliographical references and index. LLC 29 East 21st Street. New York. 87.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control.istockphoto. Rosen Educational Services. Editorial Technologies Lisa S. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. call toll free (800) 237-9932. Copyright © 2011 Encyclopædia Britannica.

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

Circulation.61 The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration. and Metabolism 73 Adaptations 78 High Altitudes 79 Swimming and Diving 81 Chapter 4: Infectious Diseases of the Respiratory System 87 Upper Respiratory System Infections 88 Common Cold 88 Sore Throat 91 Pharyngitis 91 Sinusitis 92 Tonsillitis 94 Lower Respiratory System Infections 95 Laryngitis 95 Tracheitis 96 Croup 98 Infectious Bronchitis 99 Bronchiolitis 100 Influenza 102 Whooping Cough 105 77 .

Psittacosis 107 Pneumonia 108 Legionnaire Disease 113 Tuberculosis 114 Chapter 5: Diseases and Disorders of the Respiratory System 122 Disorders of the Upper Airway 122 Snoring 123 Sleep Apnea 124 Pickwickian Syndrome 126 Diseases of the Pleura 126 Pleurisy 127 Pleural Effusion and Thoracic Empyema 127 Pneumothorax 129 Diseases of the Bronchi and Lungs 130 Bronchiectasis 130 Chronic Bronchitis 131 Pulmonary Emphysema 133 Chronic Obstructive Pulmonary Disease 136 Lung Congestion 138 Atelectasis 141 Lung Infarction 144 Cystic Fibrosis 145 Idiopathic Pulmonary Fibrosis 149 Sarcoidosis and Eosinophilic Granuloma 149 Pulmonary Alveolar Proteinosis 150 Immunologic Conditions of the Lung 151 Lung Cancer 152 Diseases of the Mediastinum and Diaphragm 156 115 123 .

165 167 181 Chapter 6: Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 159 Allergic Lung Diseases 159 Asthma 160 Hay Fever 164 Hypersensitivity Pneumonitis 166 Occupational Lung Disease 167 Silicosis 169 Black Lung 170 Asbestosis and Mesothelioma 171 Respiratory Toxicity of Glass and Metal Fibres 173 Byssinosis 174 Respiratory Toxicity of Industrial Chemicals 175 Disability and Attribution of Occupational Lung Diseases 176 Other Respiratory Conditions 177 Circulatory Disorders 177 Respiratory Distress Syndrome 179 Air Pollution 180 Carbon Monoxide Poisoning 183 Acidosis 184 Alkalosis and Hyperventilation 184 Hypoxia 186 Altitude Sickness 188 Barotrauma and Decompression Sickness 189 Thoracic Squeeze 192 Drowning 193 Chapter 7: Approaches to Respiratory Evaluation and Treatment 196 Recognizing the Signs and Symptoms of Disease 196 .

Methods of Investigation 199 Pulmonary Function Test 202 Chest X-ray 203 Lung Ventilation/Perfusion Scan 204 Bronchoscopy 205 Mediastinoscopy 208 Types of Respiratory Therapy 210 Drug Therapies 211 Oxygen Therapy 214 Artificial Respiration 218 Thoracentesis 220 Hyperbaric Chamber 221 Lung Transplantation 223 Conclusion 223 202 Glossary 226 Bibliography 228 Index 230 219 .

INTRODUCTION .

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

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

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

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

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

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

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

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

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

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

It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. the collaboration of other organ systems is essential. The Nose The nose is the external protuberance of an internal space.7 Anatomy and Function of the Human Respiratory System 7 which connect the gas–exchange region inside the body with the environment outside the body. Morphology of the upper airways The nose. whose bony framework is formed by the ribs and the thoracic vertebrae. the structures of the upper respiratory tract also have other important functions. which acts as a carrier of gases. The oral cavity. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract.. as the main respiratory muscle. Other elements fundamental to the process of respiration include the blood. the pumping action on the lung. the heart and the blood vessels). The muscles expand and contract the internal space of the thorax. is sometimes also considered a part of the upper airways. and it protects against the passage into the lungs of potentially infectious foreign agents. The filtering process is vital to clearing inhaled air of dust and other debris. such as enabling the sensation of smell.e. the nasal 21 . the nasal cavity. For respiration. sinuses. through which air may be inhaled or exhaled. and the circulatory system (i. which pumps blood from the heart to the lungs and the rest of the body. under the control of the central nervous system. and the intercostal muscles of the chest wall play an essential role by generating. In addition to fulfilling a fundamental role in respiration. The diaphragm.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Respiratory System

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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
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Anatomy and Function of the Human Respiratory System

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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.
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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.

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CHAPTER2
CONTROL AND MECHANICS OF BREATHING
he respiratory system is intimately associated with the brain and central nervous system. Indeed, the diaphragm and the muscles of the chest are innervated by neurons that connect to regions of the brain known as the pons and medulla oblongata. These regions are involved in the control of autonomic nervous activity and therefore regulate internal organs without any conscious recognition or effort. Thus, breathing is an automated function in which nerve impulses sent from the brain stimulate the respiratory muscles to contract, thereby producing the mechanical forces associated with inhalation and exhalation. These impulses give rise to every breath, and in healthy individuals they are sent faithfully for life.

T

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

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

Neurally. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. allowing the activity of these physiological systems to be coordinated with respiration. which supply the diaphragm and other thoracic and abdominal muscles. Input into the respiratory control system from higher brain centres may help optimize breathing so that not only are metabolic demands satisfied by breathing but ventilation also is accomplished with minimal use of energy. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. in turn they drive cranial motor neurons. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 .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. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla.

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

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

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

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

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

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

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

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

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

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

resulting in flow of air into or out of the lung and establishment of a new lung volume. 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. then. In summary. 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. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. its pressure rises above atmospheric pressure. This negative (below-atmospheric) pressure is a measure. the pleural pressure reflects primarily two forces: 55 . The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. A lung is similar to a balloon in that it resists stretch.7 Control and Mechanics of Breathing 7 decreases. 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. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. This tendency of the lung to collapse or pull away from the chest is measurable by carefully placing a blunt needle between the outside of the lung and the inside of the chest wall. The pressure measured in the small pleural space so created is substantially below atmospheric pressure at a time when the pressure within the lung itself equals atmospheric pressure. lung air becomes transiently compressed. This. of the force required to keep the lung distended. therefore.

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

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

Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver. The beating of cilia (hairline projections) from cells lining the airways 58 .7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. Airflow velocity. © www . with no space between the vocal cords).e.istockphoto.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. normally reaching 30 litres per minute in quiet breathing.. The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles.8 pounds per square inch) by the so-called Valsalva maneuver—a forceful contraction of the chest and abdominal muscles against a closed glottis (i. can be raised voluntarily to 400 litres per minute.

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

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

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

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. as occurs. in the flow through skeletal muscles during exercise. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. which in turn is responsive to overall body requirements. 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. the partial pressure of each gas is directly proportional to its concentration. or mass flow. Convection. Local flows can be increased selectively. but almost equal quantities of the two gases are involved in metabolism and gas exchange.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. for example. Diffusion is the primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. convection and diffusion. 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. In a mixture of gases. The rapidity of circulation is determined by the output of the heart. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. caused by differing modes of transport in the blood. The performance of the heart and circula- 62 . Respiratory gases also move by diffusion across tissue barriers such as membranes.

therefore. plays little role in oxygen exchange but is essential to carbon dioxide exchange. called the oxygen-dissociation curve. In alveoli at sea level.2 ml of oxygen per ml of blood. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. Not all of the oxygen transported in the blood is transferred to the tissue cells. The curve representing the content of oxygen in blood at various partial pressures of oxygen. The amount of oxygen 63 . Each iron atom can bind and then release an oxygen molecule. a protein contained within red cells. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). so less than 2 percent of oxygen is transported dissolved in plasma. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. the cell-free. Enough hemoglobin is present in normal human blood to permit transport of about 0.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. important determinants of gas transport. liquid portion of blood. Plasma. These systems are present mainly in the red cells. Most oxygen is bound to hemoglobin. transport of oxygen Oxygen is poorly soluble in plasma. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed. which make up 40 to 50 percent of the blood volume in most mammals. is a characteristic S-shape because binding of oxygen to one iron atom influences the ability of oxygen to bind to other iron sites.

including hydrogen ions (which determine the acidity. Conversely. Because of this decreased affinity.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. carbon dioxide. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. with the binding of oxygen. and 2. carbon dioxide. and the curve is shifted 64 . During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. as occurs with anemia or extreme exercise. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). Hemoglobin binds not only to oxygen but to other substances as well.3-DPG decrease the affinity of hemoglobin for oxygen. or pH. At rest. Although these substances do not bind to hemoglobin at the oxygen-binding sites. Reductions in normal concentrations of hydrogen ions. This reserve is available to meet increased oxygen demands. (Affinity denotes the tendency of molecules of different species to bind to one another.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-diphosphoglycerate (2. and 2.3-DPG. or 2. 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 the oxygen-dissociation curve shifts to the right.) Increases in hydrogen ions. of the blood). carbon dioxide.

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

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

bicarbonate accumulates to a much greater extent within the red cell than in the plasma. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. A few amino sites on hemoglobin are oxylabile. Because the enzyme is present only inside the red blood cell. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. however. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. 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 . Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. then transported to the plasma. The bulk of bicarbonate ions is first produced inside the cell. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. Thus. that is. 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. 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.7 Gas Exchange and Respiratory Adaptation 7 red blood cell. where the partial pressure of carbon dioxide is lower than in the blood. The simultaneous exchange of these two ions. 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. while 62 percent exists as bicarbonate in plasma. Hemoglobin acts in another way to facilitate the transport of carbon dioxide.

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

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

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

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

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. 72 .7 The Respiratory System 7 alveolar partial pressure of oxygen. In healthy lungs there is a narrow distribution of the ratio of ventilation to blood flow throughout the lung that is centred around a ratio of 1 to 1. which facilitates carbon dioxide exchange. 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. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. loss of surface area available for diffusion of oxygen. A variety of processes can interfere with this orderly exchange.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. these include increased thickness of the alveolar–capillary membrane. the greater the reduction in blood oxygenation. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange. In disease. a reduction in the alveolar partial pressure of oxygen required for diffusion. and increased ventilation will not increase blood oxygen content. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. 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 decreased time available for exchange due to increased velocity of flow. Carbon dioxide exchange. These factors are usually grouped under the broad description of “diffusion limitation. however.

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

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

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

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

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

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

Indigenous mountain species such as the At high altitudes. Bishop/National Geographic/Getty Images 79 . such as cattle. Humans and some other mammalian species. which heighten the partial pressure of oxygen at all stages. 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. both in the ambient air and in the alveolar spaces of the lung. whether undertaken deliberately or not. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. commences from the time of exposure to high altitudes. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen. which. Barry C.

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

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

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

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

640 feet) in the sea and more than 680 metres (2. At a partial pressure greater than 1. At the extreme depths now attainable by humans— some 500 metres (1. Oxygen in excess can be a poison. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. approximately in proportion to the reciprocal of the square root of the increasing gas density.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. 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. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. like an anesthetic. has the additional advantage of providing a breathing gas of lesser density.5 bar. provides a greater respiratory advantage for deep diving. The use of hydrogen. which in a mixture with less than 4 percent oxygen is noncombustible. inspired oxygen is therefore maintained at a partial pressure somewhere between 0.7 The Respiratory System 7 increased. High values of end-tidal carbon dioxide with 84 . it may cause the rapid onset of convulsions. 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.5 bar (“surface equivalent value” = 150 percent).2 and 0. 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. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner.

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

can result in a sometimes life-threatening condition known as decompression sickness. even from depths as shallow as 2 metres (6.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. 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. 86 . 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.6 feet).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

or capreomycin. it has proved successful in controlling tuberculosis.7 Infectious Diseases of the Respiratory System 7 Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. 121 . In 1995. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). amikacin. MDR TB is treatable but is extremely difficult to cure. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. in part to prevent the development and spread of MDR TB. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. XDR TB is characterized by resistance to not only isoniazid and rifampin but also a group of bactericidal drugs known as fluoroquinolones and at least one aminoglycoside antibiotic. Instead of taking daily medication on their own. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. In addition. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. Aggressive treatment using five different drugs. such as kanamycin. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. Although some patients consider DOT invasive.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 .

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

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

000 live births in these populations and is particularly concentrated in people of northwestern European descent. Infarcts that do not heal within two or three days generally take two to three weeks to heal. diminished breath sounds. when both 145 . is an inherited metabolic disorder.e. However. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). The disease has no manifestations in heterozygotes (i. It is estimated to occur in 1 per 2.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. by the mid-1980s.e. pleural rubbing. Cystic Fibrosis Cystic fibrosis. increased heartbeat. only persons inheriting a defective gene from both parents will manifest the disease). also known as mucoviscidosis. the chief symptom of which is the production of a thick. those individuals who have one normal copy and one defective copy of the particular gene involved). The dead tissue is replaced by scar tissue. moderate difficulty in breathing. sticky mucus that clogs the respiratory tract and the gastrointestinal tract.000 live births) and is very rare in people of Asian ancestry. The disorder was long known to be recessive (i. 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. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. coughing.. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. fever. It is much less common among people of African ancestry (about 1 per 17. However.. and a dull sound heard when the chest is tapped.

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

These agents may be administered by means of an inhaler or a nebulizer. 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. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. sometimes in aerosolized form.7 Diseases and Disorders of the Respiratory System 7 percent of infants with cystic fibrosis have intestinal obstruction at birth due to very thick secretions. In addition. who may pass a mutation on to their offspring. in order to fight lung infections. Medications such as dornase alfa. and fat.” which is the definitive diagnostic test for the presence of cystic fibrosis. Many patients with cystic fibrosis regularly take antibiotics. lung transplantation may be considered. are given to thin mucus. making it easier for patients to breathe. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. In severe cases. which is powered by a compressor that sprays aerosolized drug into the airways. protein. 147 . a recombinant form of the enzyme deoxyribonuclease. In addition. Mutations associated with cystic fibrosis can be detected in screening tests. These tests are effective in the identification of adult carriers (heterozygotes). facilitating its clearance from the lungs through coughing.

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

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

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

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

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

welders. jaundice. Uranium and pitchblende miners. Tumours can begin anywhere in the lung. Other risk factors include exposure to radon gas and asbestos. In cases where the cancer has spread beyond the lungs. The most common symptoms include shortness of breath. Heavy smokers have a greater likelihood of developing the disease than do light smokers. the tumour’s type and degree of invasiveness are determined. as do some workers in hydrocarbon-related processing. secondhand smoke accounts for an estimated 3. unexplained weight loss. Types of Lung Cancer Once diagnosed. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. chromium and nickel refiners. small-cell 153 . chest pain. The risk is also greater for those who started smoking at a young age. between 80 and 90 percent of all cases are caused by smoking. and susceptibility to lower respiratory infections. visible lumps. a persistent cough or wheeze. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. According to the American Cancer Society.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75.400 deaths from lung cancer in nonsmoking adults in the United States each year. and roofers. Of the two basic forms. In countries with a prolonged history of cigarette smoking. tar refiners. Lung cancer is rarely caused directly by inherited mutations. and workers exposed to halogenated ethers also have an increased incidence. such as coal processors. or bone pain may occur. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. bloody sputum.

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

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

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

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

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

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

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

narrower passages (bronchioles) and finally into the tiny. swelling and inflammation of the inner airway space (lumen) cause fluid buildup and infiltration by immune cells and excessive secretion of mucus into the airways. During an asthma attack. 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. mild persistent. Asthma is classified based on the degree of symptom severity. terminal bronchial tubes. most of these cases. Encyclopædia Britannica. which can be divided into four categories: mild intermittent. and severe persistent. which results in tightening of the airways. Although the mechanisms underlying an asthmatic episode are not fully understood. in general 161 . Inc. Consequently. air is obstructed from circulating freely in the lungs and cannot be expired.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. moderate persistent. smooth muscles that surround the airways spasm.

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

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

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

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

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

occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 . Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. but sometimes the precise agent cannot be identified.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Some species of the fungi genus Aspergillus can cause allergic reactions and mild pneumonia in susceptible individuals. or in response to a variety of other agents. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. The disease may present as an atypical nonbacterial pneumonia and may be labeled a viral pneumonia if careful inquiry about possible contacts with known agents is not made. It is occasionally attributable to Aspergillus.

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

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

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

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

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

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industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.

Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing

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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
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,

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

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

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

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

is associated with excess mortality and increased prevalences of chronic bronchitis. leads to the formation of photochemical smog. the factor most responsible for the pollution. The large number of automobiles in that city.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 in England. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. This begins with the emission Air pollution begins as emissions from sources such as industrial smokestacks. This form of pollution. respiratory tract infections in the young and old. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories.com/Jupiterimages 181 . together with the bright sunlight and frequently stagnant air. and finally the passage of legislation banning open coal burning. Photos. and possibly lung cancer. 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.

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

carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. For this reason. 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. 183 . A 4 percent increase in the blood carbon monoxide level in patients with coronary artery disease is believed to shorten the duration of exercise that may be taken before chest pain is felt. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. including combustion of gas in automobile engines. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. the subject feels dizzy and is unable to perform simple tasks. a condition in which hemoglobin is deficient. Carbon monoxide is produced by incomplete combustion. Judgment is also impaired. leaving only 60 percent available to bind to oxygen). and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. 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. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. as part of his detailed analysis of atmospheres in underground mines. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard.

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

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

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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
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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

213 . and most are rendered inactive by monoamine oxidase enzymes in the liver. In 1942.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. among them hay fever and seasonal rhinitis. Used in sufficiently large doses. The development of these antihistamines dates from about 1937. were too toxic for clinical use. Other side effects include gastrointestinal irritation. Antihistamines are readily absorbed from the alimentary tract. tested later and found to be more potent. and less toxic were prepared. nearly all antihistamines produce undesirable side effects. Antihistamines are not usually beneficial in treating the common cold and asthma. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. The first antihistamines were derivatives of ethylamine. The most common side effect in adults is drowsiness. more specific. it is unlikely that he or she will benefit from them. Nasal irritation and watery discharge are most readily relieved. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. Persons with urticaria. More than 100 antihistaminic compounds soon became available for treating patients. and certain sensitivity reactions respond well. compounds that were more potent. antihistamines can control certain allergic conditions. If a patient’s condition does not improve after three days of treatment with antihistamines. and dryness of the mouth. headache. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. subsequently. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. edema. itching. blurred vision. Anilinetype compounds.

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

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. a device inserted into the nostrils that is connected by tubing to an oxygen system. 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. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. such as chronic obstructive pulmonary disease (COPD). oxygen may be delivered through a face mask or through a nasal cannula.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. known as hyperbaric oxygen therapy (HBOT). because the procedure can potentially stimulate the generation of DNA-damaging free radicals. For patients affected by chronic lung diseases. 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. HBOT has been promoted as an alternative therapy for certain conditions. In both the hospital and the home settings. however. Another form of therapy. which is inserted directly into the trachea by way of a hole made surgically in the neck. In addition. portable compressed-gas oxygen cylinder. These applications are controversial. 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. In emergency situations. 215 .

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

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

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

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 .

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

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

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

emphysema. pulmonary 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. who may be relatively young. for example. the techniques are being pursued aggressively in specialized centres. Persons severely disabled by cystic fibrosis. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. sarcoidosis. 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. conclusion In the 21st century. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. Because transplantation offers the only hope for persons with severe lung disease. With proper selection of donor organs and proper transplantation technique. survival at one year has been reported at 90 percent.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. many people who die of severe head injuries. Availability of donor lungs is sharply limited by the number of suitable donors. often have also suffered lung injury or lung infection. 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 . but from the late 1970s bilateral lung transplantation had some striking results.

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

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

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

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

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

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

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

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

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

114 Pott disease. 203 P parasites. 56. 187 rheumatic fever. 223 scarlet fever. 159. 179–180 Reynaud disease. 93 congestion of. 125. 93 sinusitis. 92. 87. 180. 221 pollution. 208.Wilhelm Conrad. 113. 103. 33. 85 nose cilia. 152. 167. 45. 170. 128. 50 nitrogen narcosis. 92–94. 87.7 olfactory. 118 prostaglandins. 126–130. 50 psittacosis. 103. 200. 53. 107 penicillin. 100 rhinoviruses. 106. 214. 95 shunting. 107–108. 179 rheumatoid arthritis. 198. 91. 92. 211. 127. 33. 194 pulmonary parenchyma. 126. 146. 149–150. 104 osteoporosis. 127. 89 structure and function of. 214 pertussis. 160 sleep. 24–25 pickwickian syndrome. 220 pleurisy. 154. 168–169. 91. structure and function of. 170 pneumonia. 172. 41. 26. 126. 139. 209. 108. S sarcoidosis. 111 parrot fever. 220 pneumothorax. 124. 198 pneumoconiosis. 84. 108. 85. 208. 211. 136 233 . 88 rimantadine. 155. 103. 50. 34 pyothorax. 19. 91. 180–182 pons. 99 Index 7 O obesity. 214–218 128. 127–129. 141. 198 pleural effusion. 114. 138. 105–106. 173. 93. 117. 164 pharyngitis. 57. 184. 23–24 sinus. 87. 122 function of. 44 Pontiac fever. 198. 38. 94. 137 oxygen therapy. 130. 88. 139. 110 pulmonary alveolar proteinosis. 52–53. 69–71 silicosis. 189. 178. 169–170 sinuses. 150–151 pulmonary edema. 122. 214 pharynx. 91–92. 131. 36. 107. 47 vagus. 107. 129–130. 31–32. 22. 126 pleura. 126 oseltamivir. 128 R Relenza. 22 irrigation of. 136. 95. 164 inflammation of. 21–24. 108–113. 137. 104–105 respiratory distress syndrome. 103 Röntgen.

108. 124 W whooping cough. 99. 92 streptococcal bacteria. 69 vestibular folds. false. 136. 104 tetanus. 114–121. 131–132. 25. 96–98 trench mouth. 214 surgery. 92. 143. 56. 127–129 thoracic squeeze. 171. 218 sneezing. 103. 182. 58 ventilation–blood flow imbalance. 138. 198. 95. 150. 107. 87. 53. 91. 21. 93. 23–24. 97. 192–193 tonsillitis. 122. 27–28 vitamin C. 104–105 234 . 110. 129. 81–86 syphilis. 172. 220 typhoid. 87. 95. 96. 94–95 tonsils. 109.7 The Respiratory System 7 smallpox.102. 91. 103. 92. 92. 175. 97. 28–30 tracheitis. 155–156. 94 staphylococci. 209 swimming. 170. 53. 97 trachea. 123–124 sore throat. 220–221 thoracic emphyema. 125. 116. 199. 106. 96. 92. 164. 171. 91 vocal chords. 138. 27–28 T Tamiflu. 197. 130. 95. 178. 123. 118. 91. 87. 93. 163. 97 V vaccination. 164 snoring. 78. 119. 133–135. 105–107 Z zanamivir. 106 thoracentesis. 153. 99. 97. 122. 92. 102. 95 tuberculosis. 94 smoking. 88. 94. 111. 173 Valsalva maneuver. 152. 103. 33. 97. 138. 183. 97 smell. 146 strep throat. 176. 199. 164. structure and function of. 128. 137. 94–95. 130. 204. 208.

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