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

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

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

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

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

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

INTRODUCTION .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

in turn they drive cranial motor neurons. Neurally. Input into the respiratory control system from higher brain centres may help optimize breathing so that not only are metabolic demands satisfied by breathing but ventilation also is accomplished with minimal use of energy. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. which supply the diaphragm and other thoracic and abdominal muscles. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. allowing the activity of these physiological systems to be coordinated with respiration. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors.

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

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

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

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

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

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

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

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

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

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

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

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

it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). capable of increasing its output 25 times. At total relaxation of the muscles of inspiration and expiration. such as pieces of glass. separated by a film of water. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9.154 cubic inches) per minute in adults. The volume in these circumstances is known as the residual volume. The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. expiration being accomplished “passively” by elastic recoil of the lung. During ordinary breathing. Pressures 57 . 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. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. The respiratory pump is versatile.

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

respectively. and seven litres.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. 500 millilitres. 59 . Normal lungs. 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.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. however. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces. totaling about 0. 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. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. In fact. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae.

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

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

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

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

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

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

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

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

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

g. 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. and limitations of diffusion. alveoli filled with fluid or inflammatory material). These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. ventilation– blood flow imbalance. In shunting. shunting. venous blood enters the bloodstream without passing through functioning lung tissue. A reduction in arterial blood oxygenation is seen with shunting. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation.. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. Because of the differences in oxygen and carbon dioxide transport.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. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. but the level of carbon dioxide in arterial blood is not elevated even 69 . 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.

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

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

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

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

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

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

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

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

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

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

Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. the size of muscle fibres decreases. the carotid bodies enlarge but become less sensitive to the lack of oxygen.3DPG. exhibit an adaptation that is heritable and has a genetic basis. such as 2.7 The Respiratory System 7 llama. thought to enhance oxygen perfusion of the lung apices. where oxygen is needed for the ultimate biochemical expression of respiration. 80 . from the alveolar spaces in the lung to the mitochondria in the cells. In addition. As the oxygen deprivation persists. which also shortens the diffusion path of oxygen. on the other hand. and. 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. With a prolonged stay at altitude. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. which takes the form of deeper breathing rather than a faster rate at rest. the tissues develop more blood vessels. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. as capillary density is increased. attached to the division of the carotid arteries on either side of the neck. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. Diffusion of oxygen across the alveolar walls into the blood is facilitated. The low oxygen partial pressure in the lung is associated with thickening of the small blood vessels in pulmonary alveolar walls and a slight increase in pulmonary blood pressure. the carotid bodies. which increases the amount of oxygen transported to the tissues.

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

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

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

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

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

Other possible causes of pulmonary barotrauma include retention of gas by a diseased portion of lung and gas trapping due to dynamic airway collapse during forced expiration at low lung volumes. can result in a sometimes life-threatening condition known as decompression sickness. even from depths as shallow as 2 metres (6. 86 .6 feet).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. 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. 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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and by a tendency for excessive mucus production in the airway. particularly lung cancer.000 people in the United Kingdom and roughly 119.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. Frequent exacerbations. which gives rise to symptoms of bronchitis. tobacco-related condition. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. Exacerbations are triggered by infection. Although primarily a lung disease. and the burning of certain fuels in poorly ventilated areas. are not always required. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. either bacterial or viral. it is increasingly recognized that COPD has secondary associations.000 people in the United States die from COPD. COPD is distinguished pathologically by the destruction of lung tissue. indicate a poor prognosis. which causes increased lung volume and manifests as breathlessness. Coughing up blood is not a feature of COPD and when present raises concern about a second. and each year about 30. which 137 . particularly if severe enough to warrant hospital admission. including muscle weakness and osteoporosis. Sources of noxious particles that can cause COPD include tobacco smoke. Therefore. air pollution. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). antibiotics. It is a common disease. which work against bacteria. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. which is replaced by holes characteristic of emphysema. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

emphysema. control of the disease lies mainly in prevention. and the abdominal lymph nodes. and. difficulty in breathing. cannot be digested by the macrophages and instead kill them. and particles of one to three microns do the most damage. Lung volume is reduced. and pneumonia. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. Silicosis predisposes a person to tuberculosis.000.0004 inch) in diameter penetrate to the finer air passages of the lungs. also known as coal-worker’s pneumoconiosis. that serve to protect the body from bacterial invasion. Silica particles.000 particles of silica per cubic foot (about 210. Black Lung Black lung. since there is no effective treatment. In the past a large proportion of sufferers of silicosis died of tuberculosis. Only very small silica particles less than 10 microns (0. however.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. and weakness. is a respiratory disorder caused by repeated inhalation of 170 . The symptoms of silicosis are shortness of breath that is followed by coughing. These whorls of fibrous tissue may spread to involve the area around the heart. The use of protective face masks and proper ventilation in the workplace and periodic X-ray monitoring of workers’ lungs has helped lessen the incidence of the disease. In the actual disease process. There is no cure for silicosis. and gas exchange is poor. the openings to the lungs. called macrophages. though this has changed with the availability of drug therapies for that disease.000 per litre) of air.

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

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

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

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

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

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

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

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

leaving only 60 percent available to bind to oxygen). a condition in which hemoglobin is deficient. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. Carbon monoxide is produced by incomplete combustion. 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. as part of his detailed analysis of atmospheres in underground mines. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. For this reason. 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. Judgment is also impaired.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). 183 . 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. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. 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.

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

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

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

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

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

although they lack evidence of life. Until recently. Any symptoms of thoracic squeeze call for prompt medical attention. their lungs. pulse. These aquatic mammals have been found to have more elastic chest cavities than humans. 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. and gives up the remaining tidal air in his or her lungs. or breathing—at the time of rescue.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The predominant symptom felt by the diver is pain when the pressure becomes too great. There the heart may continue to beat feebly for a brief interval. The sperm whale is reported to dive to about 1. A fuller appreciation of the 193 . may exhale frothy blood.000 metres (3.300 feet). Drowning Drowning is suffocation by immersion in a liquid. more than 10 times the depth that humans can tolerate. which can be relieved by ascending. and may even become unconscious. It is now known that victims immersed for an hour or longer may be totally salvageable. physically and intellectually. do not separate from the chest wall. If the thoracic squeeze has been sufficient to cause lung damage. 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. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. usually water. Artificial respiration may be necessary if the breathing has stopped. but eventually it ceases. having no measurable vital signs—heartbeat. the diver may have difficulty in breathing. loses consciousness. even when reduced. and their bodies are adapted to use the gases in the bloodstream more conservatively. Deprived of oxygen the victim stops struggling.

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

Such warmwater drownings occur commonly in domestic bathtubs. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. None of these effects is imminently life-threatening. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia. survival following hypothermic coma is almost 75 percent. 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. 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). 195 .” “Lifeless” immersion victims with core temperatures as low as 62.6 °F (17 °C) have survived. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. and promotes unconsciousness.

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

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

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

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

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

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

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

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

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

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

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

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

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

7 Approaches to Respiratory Evaluation and Treatment 7 methods by which tissue samples are collected from the mediastinal lymph nodes for the staging of lung cancer. immediately above the sternum. Severe complications— such as bleeding. infection. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. light-emitting. the doctor is able to investigate the surfaces of the various structures. The biopsy samples are then investigated for evidence of abnormalities. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). This may also be performed for other tissues in the region that display signs of disease. a surgeon first makes a small incision in the patient’s neck. 209 . In cancer staging. and the procedure is associated with a very low risk of complications. Staging involves the investigation of cells to assess the degree to which cancer has spread. During mediastinoscopy. This step of the procedure is known as mediastinotomy. such as abnormal growths or inflammation. By carefully maneuvering the scope in the space. flexible instrument—is then passed through the incision and into the space between the lungs. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. Most patients recover within several days following mediastinoscopy. which is performed under general anesthesia. A mediastinoscope—a thin. particularly for cellular defects associated with cancer and for the presence of infectious organisms. including computerized axial tomography and positron emission tomography.

such as bronchodilators. Medications. and maintenance of mechanical ventilators. produces vibrations that help to loosen and mobilize secretions. and antibiotics. performed manually or by means of a handheld percussor or vest. Aerosol humidifiers called nebulizers may be powered by compressor machinery or by a hand-squeezed bulb to project medication or water spray into the airway. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. or a fog (as in an oxygen tent or a croup tent).7 The Respiratory System 7 types of respiratory therapy Respiratory therapy is primarily concerned with assisting or improving the respiratory function of individuals with acute or chronic lung disease. 210 . Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. Therapy may involve the administration of gases for inhalation. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. Oxygen may be administered in controlled amounts to assist laboured breathing. as in treatment of cystic fibrosis. respiratory therapists are experts in the setup. adjustment. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. In addition. One of the conditions frequently dealt with is obstruction of breathing passages. There are different methods of treatment employed in respiratory therapy. 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. mucolytics. each of which may be tailored to a specific disease. Chest percussion. hot steam.

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

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

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

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

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

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

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

218 . Artificial Respiration Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. and pharynx) to the lungs and 2.7 The Respiratory System 7 properly. oxygen can readily spread fire. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. or other sources of ignition. can prevent some deaths from drowning. carbon monoxide poisoning. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1. Such techniques. choking. lifts the lower jaw forward and upward to open the air passage. clears his mouth of foreign material and mucus. establishing and maintaining an open air passage from the upper respiratory tract (mouth. Likewise. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. which has been found to be more effective than the manual methods used in the past. suffocation. throat. if applied quickly and properly. The person using mouth-to-mouth breathing places the victim on his back. they may cause explosions. Furthermore. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. and electric shock. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. candles. strangulation. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal.

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 .

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

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

5 to 3 times higher than ordinary atmospheric pressure. 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. Chris McGrath/ Getty Images used for medical treatment are usually 1. or from a combination of the two. which increases oxygen availability to the body in therapeutic treatment. 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). 222 .7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. for example. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects.

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. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. the techniques are being pursued aggressively in specialized centres. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery.7 Approaches to Respiratory Evaluation and Treatment 7 Lung Transplantation Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. often have also suffered lung injury or lung infection. pulmonary fibrosis. survival at one year has been reported at 90 percent. which presumably would leave the lungs intact. Because transplantation offers the only hope for persons with severe lung disease. emphysema. conclusion In the 21st century. 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 . With proper selection of donor organs and proper transplantation technique. Persons severely disabled by cystic fibrosis. but from the late 1970s bilateral lung transplantation had some striking results. many people who die of severe head injuries. Availability of donor lungs is sharply limited by the number of suitable donors. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. sarcoidosis.

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

For example. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. 225 . 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. As researchers and physicians continue to uncover new information about the human respiratory system. In addition. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. as well as new treatments.7 Approaches to Respiratory Evaluation and Treatment 7 Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease.

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

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

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

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

86. 75 acidosis. 212–214 aortic body. 103. 102. Paul. 169. 51. 111. 170–171 Bordet. 152–156. 46. 169. 76. 171 AIDS. 129. 194 asthma. 112–113. 127. 92. 166 black lung. 122. 173. 96. 197 bronchopulmonary dysplasia. structure and function of. 136. 111 Adam’s apple. 209 animals. 196. 124–125. 85 artificial respiration. 97. 171–173 asphyxiation. 213 atelectasis. 106 bradykinin.INDEX A acid–base balance. 230 . 141–144 B barotrauma. 81. 46. 64. 33–34 stem. 52. 198. 135. 160–164. 153. 77 Agricola. 221 asbestosis. 134. 27 adenosine triphosphate (ATP). 181. 211. 184 Actinomyces. 171 antibiotics. 137. 152. 34–35 amantadine. 79–80. 42. 116. 186. 197. 28–29 bronchiectasis. 189–192. 73. 217 Bert. 30. 187 byssinosis. Josef. 35. 171–173. 211. 81. 175. 30. 38. 109. 208. 39 alcoholism. 75. 131–133. 111. 94. 176.130–131. 123. 118–119 air–blood barrier. 126 arterial gas embolism. 137. 187 anesthesia. 218–220 asbestos. 159. 103 anemia. 91. 169 lung. 152. 188 bird fancier’s lung. 52. 99–100. 217 bronchoscopy. 74. 127. 210. 117. 50 Breuer. 33–34 bronchiolitis. 223 bronchitis. 115. 30. 49 bronchi. 205–208 brown lung. 108. structure of. 169. 193 anthracosis. 171. 110. structure of. 184–186 altitude sickness. 184. 168. 48 apnea. 198 bronchioles. 174 Buerger disease. 100–102. 159. 107. Jules. 147. 164. 93. 168–169. 175. Georgius. 114. 188–189 alveoli. 174–175 C cancer. 172. 131. 113 alkalosis. structure and function of. 214 antihistamines. 182.

137. 75–78. 193–195. 47. 171. 189–192. 47. 151 D decompression sickness. 72 diphtheria. 78. 211–212 diaphragm. 218 dyspnea. 30. 190. 150 epiglottis. 67 chronic obstructive pulmonary disease (COPD). 67. Octave. 117. 56. 149. 94. 106. 209. 119 231 . 86. 164. 147. 69–72 Gengou. 215. 190 histamine. 160 HIV. 145–148. 186. 223 7 E emphysema. 79–81. 91. 137. 81 central nervous system disease. 80. 175. 183 hay fever. 58–59. common. 164 coughing blood. 132. 138. 221 cardiopulmonary resuscitation (CPR). 95. 27. 50. 221. 48. 84. 65. 75. 21. 50. 108. 220. 157–158. 44. 196–197. 210. 87. 102. 217 Clara cells. 197–198 H Haldane. 63. 30 Goodpasture syndrome. 174. 222 decongestants. 133–136. 130. 198 croup. 112. 97. 122. 49 Hering-Breuer reflex. 65. 201. 216–217 Hering. 211. 52 chloride shift. 161. 25. 122. 81–86. 106. 190. 215. 122. 60. 197. 84. 183. 46. 187. 212 exercise (training). 88–91. John Scott. 50. 158 diffusion limitation. 98. 136. 177. 207 physiology of. 78. 94. 145. 51–52. 182. 143. 159. 196.7 Index 181. 166 fungi. 183. 34 cold. 182 G gas exchange. 105–106. 92. 87. 168. 115. 81. 64. 137. 135. 62. Ewald. 184. 130. 204. 49 high altitudes. 187. 131. 156–158. 127–129. 180. 199. 201 F farmer’s lung. 47. 159. 95. 80. 98. 130. 129. 191–193 drowning. 25. 136–138. 144. 215 carotid body. 98–99 epiglottitis. 52 Cheyne-Stokes breathing. 192. 69. 188–189. 96. 214 diving. 132 types of. 213 cause of. abnormal. 170. 88 corticosteroids. 93. 106 glycolysis. 158. 64. 213 hemoglobin. 98–99 epinephrine. 111. 85. 156. 66. 198. 197. 98–99 cystic fibrosis. 98. 74 goblet cells. 223 eosinophilic granuloma.

99 mediastinoscopy. 93. 113–114. 127. 81–82. 52. 143. 214 leukemia. 81 aerobic. 221–222 hypercapnia. 199. 215. 102–105. 74. 144–145. 184 L Laënnec. 204–205 M measles. 88. 41. 87. 100 lungs N nephritis. 119 hyperbaric chamber. 138. 149 influenza. 74. 92. 178. 167. 171–173. 125 hypoventilation. René-ThéophileHyacinthe. 127. 196 laryngitis. 81 mountain sickness. 69. 37. 73–78. 26–28 Legionnaire disease. 126 hypoxemia. 176. 26. 117 mesothelioma. 135–136. 87. 95–96 larynx. 76 Monge disease. 186–188 I idiopathic pulmonary fibrosis. 145 K kidney. 198. 198. 104 vaccine. 96. 55–56. 44. 127 hygiene. 110. 45. 190. 51–52. 182. 147. 26 232 . 103. 70. 184–186 hypothyroidism. 159 congestion of. 173 cancer of. 103 H1N1. structure and function of. 50 meningitis. 208 medulla. 31. 76–77. 91. 178. 151. 38. 38–40 infarction. 149. 163 hydrothorax. 31 transplantation of. 83. 94. 81 mucoviscidosis. 68. 129. 138. 78 anaerobic. 141. 150. 122. 139. 156–158. 152–156. 83 hypersensitivity pneumonitis. 209. 181. 114–115. 169. 173. 204. 149.7 The Respiratory System 7 hookworm. 47. 46–48. 221 collapse of. 138–141. 177 size of. 172. 221 metabolism. 98. 166–167 hyperventilation. 50. 94 nerves laryngeal. 117. 208–209 mediastinum. 173. 114. 217 hypoxia. 99. 128. 197 development of. 110. 199 bird flu. 49. 215. 223 lung ventilation/perfusion scan.

146. 107. 139. 104–105 respiratory distress syndrome. 198 pneumoconiosis. 57. 108. 106. 113. 129–130. 45. 52–53. 126. 87. 122 function of. 208. 91. 150–151 pulmonary edema. 34 pyothorax. 170 pneumonia. 108–113. 214 pharynx. 108. 137 oxygen therapy. 56. 211. 126. 214–218 128. 128 R Relenza. 169–170 sinuses. 149–150. 110 pulmonary alveolar proteinosis. 114. 103 Röntgen. 26. 141. 21–24. 91–92. 114 Pott disease. 85 nose cilia. 124. 173. 84. 100 rhinoviruses. 198. 184. 211. 19. 152. 122. 22. 179 rheumatoid arthritis. 164 pharyngitis. 127–129. 220 pleurisy. 33. 23–24 sinus. 223 scarlet fever. 93 sinusitis. 92. 24–25 pickwickian syndrome. 168–169. 118 prostaglandins. 126–130. 138. 95 shunting. 50 psittacosis. 31–32. 220 pneumothorax. 93. 99 Index 7 O obesity. 127. 53. 214. 160 sleep. 221 pollution. 50 nitrogen narcosis. 103. 92. 198. 107. 179–180 Reynaud disease. 127. 194 pulmonary parenchyma. 111 parrot fever. 107–108. 189. 154. 47 vagus. 44 Pontiac fever. 50. 105–106.7 olfactory. 91. 87. 208. 155. 95. 117. 104 osteoporosis. 164 inflammation of. 33. 187 rheumatic fever. 139. 87. 94. 103. 92–94. 107 penicillin. 88 rimantadine. 203 P parasites. 88. 136 233 . 214 pertussis. 69–71 silicosis. 91. 126 oseltamivir. 167. 198 pleural effusion. 93 congestion of. 85. 180. 131. 89 structure and function of. 178. 41. 170. S sarcoidosis. 130. structure and function of. 103. 180–182 pons. 159. 36. 200. 137. 172. 22 irrigation of. 38. 126 pleura. 128.Wilhelm Conrad. 209. 125. 136.

116. 97 V vaccination. 198. 150. 208. 92. 23–24. 153. 128. 94 smoking. 204. 114–121. 175. 92. 96–98 trench mouth. 183. 99. 21. 119. 209 swimming. 164. 218 sneezing. 220–221 thoracic emphyema. 122. 97. 53. 87. 92. 93. 104–105 234 . 133–135. 102. 131–132. 171. 97. 97 smell. 97. 97. 104 tetanus. 118. 123. 199. 91. 81–86 syphilis. 78.102. structure and function of. 171. 94 staphylococci. 33. 107. 182. 106 thoracentesis. 138. 111. 136. 58 ventilation–blood flow imbalance. 69 vestibular folds. 95. 93. 143. 103. 91. 95 tuberculosis. 92. 127–129 thoracic squeeze. 95. 56. 220 typhoid. 103. 88. 94–95 tonsils. 164. 164 snoring. 173 Valsalva maneuver. 27–28 vitamin C. 163. 99. 53. 87. 130. 91 vocal chords. 155–156. 214 surgery. 170. 192–193 tonsillitis. 146 strep throat. 95. 97 trachea. 138. 92. 130. 28–30 tracheitis. 110. 172. false. 178. 94. 123–124 sore throat. 176. 129. 96. 152. 122. 87. 105–107 Z zanamivir. 106. 27–28 T Tamiflu. 25. 199. 108. 109. 94–95. 124 W whooping cough. 96.7 The Respiratory System 7 smallpox. 91. 125. 197. 137. 103. 92 streptococcal bacteria. 138.