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

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

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

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

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

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

INTRODUCTION .

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

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

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

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

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

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

In the early 20th century. In addition to vaccines and antivirals. Nasal decongestants and antihistamines are examples of commonly used remedies. although tobacco smoking is the primary cause. There is hope for those who suffer from respiratory diseases and disorders. factors. The best-known occupational lung disease is black lung. or white lung disease. resulting in an estimated 1. Breathing problems caused by allergies to environmental conditions are fairly common. Doctors first described the symptoms of lung cancer in the mid-19th century. which affects coal miners who inhale coal dust for many years. Some respiratory diseases arise as a result of occupational. lung cancer is the leading cause of cancer deaths worldwide. however. Scientists are constantly researching and developing new and different treatments for respiratory ailments. Now. Many treatments. most likely resulting from exposure to air pollution. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. Construction workers and insulators exposed to asbestos often suffer from asbestosis. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. more than 7 percent of children and 9 percent of adults suffer from asthma. Breathing asbestos can also cause the cancerous condition known as mesothelioma. 17 .3 million fatalities each year. particularly pneumonia and tuberculosis. however. Several vaccines have been developed to prevent illnesses such as influenza. it was still considered rare. The antiviral agents Tamiflu (oseltamivir) and Relenza (zanamivir) played an important role in treating persons affected by influenza during the H1N1 influenza pandemic of 2009. have been around for years and are readily available. and even cockroaches.7 Introduction 7 variety of factors. or work. tobacco smoke. Today.

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

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

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

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

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

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

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

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

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

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

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

The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. a peripheral. The structure of the stem bronchi closely matches that of the trachea. if the trachea is counted as generation zero. however. Individual paths. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. may range from 11 to 30 generations. From a morphological point of view. In modeling the human airway tree. it is generally agreed that the airways branch according to the rules of irregular dichotomy. however. purely gas-exchanging zone. it makes sense to distinguish the relatively thick-walled. Functionally. and a transitional zone in between. structural design of the airway tree The hierarchy of the dividing airways. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions.7 Anatomy and Function of the Human Respiratory System 7 this arrangement is that foreign bodies passing beyond the larynx will usually slip into the right lung. purely conducting zone. the intrapulmonary airway system can be subdivided into three zones: a proximal. largely determines the internal lung structure. 29 . purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. the daughter branches may differ greatly in length and diameter. and partly also of the blood vessels penetrating the lung. where both functions grade into one another. In irregular dichotomy. however.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.7 Control and Mechanics of Breathing 7 medulla. Receptors. there is a length at which the force generated is maximal. which excites stretch receptors in the airways. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. called spindles. another receptor in muscles. in the respiratory muscles measure muscle length and increase motor discharge to the diaphragm and intercostal muscles when increased stiffness of the lung or resistance to the movement of air caused by disease impedes muscle shortening. Generally. Tendon organs. The Hering-Breuer reflex is initiated by lung expansion. Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. 49 . 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. 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. Stimulation of these receptors. monitor changes in the force produced by muscle contraction.

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

Shutterstock. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide.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. A number of signals arise during exercise that can augment ventilation. and thermal receptors. and thermal receptors all work in concert during exercise to enhance ventilation.com 51 . the arterial chemoreceptors. Sources of these signals include mechanoreceptors in the exercising limbs. arterial chemoreceptors. because body temperature rises as metabolism increases. thus preserving acid–base homeostasis. Mechanoreceptors.

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

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

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

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

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

from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. capable of increasing its output 25 times. The respiratory pump is versatile. Pressures 57 . it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. At total relaxation of the muscles of inspiration and expiration.154 cubic inches) per minute in adults. 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. muscular contraction occurs only on inspiration. 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. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. During ordinary breathing.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. separated by a film of water. expiration being accomplished “passively” by elastic recoil of the lung. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. such as pieces of glass.

istockphoto.7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx. normally reaching 30 litres per minute in quiet breathing.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1.8 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. can be raised voluntarily to 400 litres per minute. © www . with no space between the vocal cords).e. The beating of cilia (hairline projections) from cells lining the airways 58 . Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.. Airflow velocity.

59 . and seven litres. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. respectively. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. An infant takes 33 breaths per minute with a tidal volume (the amount of air breathed in and out in one cycle) of 15 millilitres. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. such adherence occasionally does occur and is one of the dreaded complications of premature births. In fact. however. 500 millilitres. Normal lungs. totaling about 0.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths.

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

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

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

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

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

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

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

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

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

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

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

reaches a plateau at the normal alveolar partial pressure. a plateau is reached at the 71 . however. In the healthy area of the lung. cannot compensate in terms of greater oxygenation for underventilated alveoli because. 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. 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. Mixture of blood from this healthy portion of the lung (with normal oxygen content) and blood from the abnormal area of the lung (with decreased oxygen content) produces a composite arterial oxygen content that is less than the normal level. the amount of carbon dioxide eliminated is increased. and each alveolus receives approximately equal quantities of both. Thus.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. Overventilated alveoli. and an increase in blood partial pressure results in a negligible increase in oxygen content. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. 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. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. In alveoli that are overventilated. however. in the arterial blood. therefore. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. The oxygen-dissociation curve. Inspired air and blood flow normally are distributed uniformly.

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

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

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

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

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

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

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

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

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

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

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

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

like an anesthetic. 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. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels. The use of hydrogen.7 The Respiratory System 7 increased. provides a greater respiratory advantage for deep diving. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. 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. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic.5 bar. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. which in a mixture with less than 4 percent oxygen is noncombustible. approximately in proportion to the reciprocal of the square root of the increasing gas density. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. High values of end-tidal carbon dioxide with 84 . At a partial pressure greater than 1.5 bar (“surface equivalent value” = 150 percent).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. In mixed-gas diving. has the additional advantage of providing a breathing gas of lesser density. At the extreme depths now attainable by humans— some 500 metres (1.640 feet) in the sea and more than 680 metres (2.2 and 0. Oxygen in excess can be a poison.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lung cancer was first described by doctors in the mid-19th century. More rarely. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. In women. These conditions have only recently been recognized and differentiated. lung cancer is the second leading cause of death from cancer globally. it has surpassed breast cancer. however. Pleural effusions may occur. lung cancer emerged as the leading cause of cancer deaths worldwide. Lung Cancer Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs.3 million deaths each year. The rapid increase in the worldwide prevalence of lung cancer was attributed mostly to the increased use of cigarettes following World War I. by the use of pulmonary function tests. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. In the United States. a slowly obliterative disease of small airways (bronchiolitis) occurs. 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. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. 152 . The common condition of rheumatoid arthritis may be associated with scattered zones of interstitial fibrosis in the lung or with solitary isolated fibrotic lesions. and the lung parenchyma may be involved. In the early 20th century it was considered relatively rare. resulting in an estimated 1.7 The Respiratory System 7 known as pulmonary hemosiderosis. which is also believed to have an immunologic basis. In the 21st century. following breast cancer. leading finally to respiratory failure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and abnormally low levels of oxygen in the arterial blood. These changes contribute to the shortness of breath and account for the blood staining of the sputum. In infants it is also called hyaline membrane disease. particularly those born to diabetic mothers. or approximately 5. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. cyanosis (a bluish tinge to the skin or mucous membranes). but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. it also sometimes develops in full-term infants. respiratory distress syndrome of infants was frequently fatal. which does the work of the lungs by oxygenating the 179 . Although respiratory distress syndrome occurs mostly in premature. low-birth-weight infants (those weighing less than 2.5 pounds). The syndrome was formerly the leading cause of death in premature infants. This complication is especially common in premature newborns. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. It is characterized by extremely laboured breathing. 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.5 kg. The disorder arises because of a lack of surfactant.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). a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. Before the advent of effective treatment. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation.

Recovery and repair of the lung may take months after clinical recovery from the acute event. but not all. This episode spurred renewed attention to this problem. bacterial or viral pneumonia. Many. 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. In adults. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. aspiration of material into the lung (including water in near-drowning episodes). Most children who survive have no aftereffects. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. widespread bilateral lung injury. of the victims already had chronic heart or lung disease. This syndrome is known as acute respiratory distress syndrome of adults.000 people during that week and the subsequent three weeks. Acute respiratory distress syndrome carries about a 50 percent mortality rate. which had been intermittently considered since the 14th century 180 . It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. Life-support treatment with assisted ventilation rescues many patients. although superimposed infection or multiple organ failure can result in death. Air Pollution The disastrous fog and attendant high levels of sulfur dioxide and particulate pollution (and probably also sulfuric acid) that occurred in London in the second week of December 1952 led to the deaths of more than 4. Many causes of respiratory distress syndrome of adults have been identified. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. exposure of the lung to gases.7 The Respiratory System 7 blood and removing carbon dioxide.

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

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

a condition in which hemoglobin is deficient. 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. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. leaving only 60 percent available to bind to oxygen). as part of his detailed analysis of atmospheres in underground mines. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. The carbon monoxide inhaled by smokers who smoke more than two packs of cigarettes a day may cause up to 10 percent hemoglobin saturation with carbon monoxide. including combustion of gas in automobile engines. 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. For this reason. Carbon monoxide is produced by incomplete combustion. 183 . and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. the subject feels dizzy and is unable to perform simple tasks. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. 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.

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

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

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removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, respiratory alkalosis ensues. In turn, alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, including light-headedness and tingling of the fingertips. Severe hyperventilation can cause transient loss of consciousness. Anxiety is the most common cause of hyperventilation. Panic disorder, a severe episodic form of anxiety, usually causes hyperventilation with resultant symptoms. Treatment of recurrent hyperventilation begins with a complete explanation by the patient of the condition and the symptoms it causes. Some people benefit from psychotherapy and medications to deal with the underlying anxiety.

Hypoxia
Hypoxia is a condition of the body in which the tissues are starved of oxygen. In its extreme form, where oxygen is entirely absent, the condition is called anoxia. There are four types of hypoxia: (1) the hypoxemic type, in which the oxygen pressure in the blood going to the tissues is too low to saturate the hemoglobin; (2) the anemic type, in which the amount of functional hemoglobin is too small, and hence the capacity of the blood to carry oxygen is too low; (3) the stagnant type, in which the blood is or may be normal but the flow of blood to the tissues is reduced or unevenly distributed; and (4) the histotoxic type, in which the tissue cells are poisoned and are therefore unable to make proper use of oxygen. Diseases of the blood, the heart and circulation, and the lungs may all produce some form of hypoxia.

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The hypoxemic type of hypoxia is due to one of two mechanisms: 1. a decrease in the amount of breathable oxygen—often encountered in pilots, mountain climbers, and people living at high altitudes— due to the reduced barometric pressure, or 2. cardiopulmonary failure in which the lungs are unable to efficiently transfer oxygen from the alveoli to the blood. In the case of anemic hypoxia, either the total amount of hemoglobin is too small to supply the body’s oxygen needs, as in anemia or after severe bleeding, or hemoglobin that is present is rendered nonfunctional. Examples of the latter case are carbon monoxide poisoning and methoglobinuria, in both of which the hemoglobin is so altered by toxic agents that it becomes unavailable for oxygen transport, and thus of no respiratory value. Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock. Local stagnant hypoxia may be due to any condition that reduces or prevents the circulation of the blood in any area of the body. Examples include Raynaud disease and Buerger disease, which restrict circulation in the extremities; the application of a tourniquet to control bleeding; ergot poisoning; exposure to cold; and overwhelming systemic infection with shock. In histotoxic hypoxia the cells of the body are unable to use the oxygen, although the amount in the blood may be normal and under normal tension. Although

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characteristically produced by cyanide, any agent that decreases cellular respiration may cause it. Some of these agents are narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents.

Altitude Sickness
Altitude sickness, sometimes called mountain sickness, is an acute reaction to a change from sea level or other lowaltitude environments to altitudes above 2,400 metres (8,000 feet). Altitude sickness was recognized as early as the 16th century. In 1878 French physiologist Paul Bert demonstrated that the symptoms of altitude sickness are the result of a deficiency of oxygen in the tissues of the body. Mountain climbers, pilots, and persons living at high altitudes are the most likely to be affected. The symptoms of acute altitude sickness fall into four main categories: 1. respiratory symptoms such as shortness of breath upon exertion, and deeper and more rapid breathing; 2. mental or muscular symptoms such as weakness, fatigue, dizziness, lassitude, headache, sleeplessness, decreased mental acuity, decreased muscular coordination, and impaired sight and hearing; 3. cardiac symptoms such as pain in the chest, palpitations, and irregular heartbeat; and 4. gastrointestinal symptoms such as nausea and vomiting. The symptoms usually occur within six hours to four days after arrival at high altitude and disappear within two to five days as acclimatization occurs. Although most
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people gradually recover as they adapt to the low atmospheric pressure of high altitude, some persons experience a reaction that can be severe and, unless they return to low altitude, possibly fatal. At higher altitudes, the air becomes thinner and the amount of breathable oxygen decreases. The lower barometric pressures of high altitudes lead to a lower partial pressure of oxygen in the alveoli, or air sacs in the lungs, which in turn decreases the amount of oxygen absorbed from the alveoli by red blood cells for transport to the body’s tissues. The resulting insufficiency of oxygen in the arterial blood supply causes the characteristic symptoms of altitude sickness. The main protection against altitude sickness in aircraft is the use of pressurized air in cabins. Mountain climbers often use a mixture of pure oxygen and air to relieve altitude sickness while climbing high mountains. In addition, the prophylactic use of the diuretic acetazolamide initiated two to three days before ascent may prevent or mitigate acute altitude sickness. A more serious type of altitude sickness, high altitude pulmonary edema (HAPE), occurs rarely among newcomers to altitude but more often affects those who have already become acclimated to high elevations and are returning after several days at sea level. In pulmonary edema, fluid accumulates in the lungs and prevents the victim from obtaining sufficient oxygen. The symptoms are quickly reversed when oxygen is given and the individual is evacuated to a lower area.

Barotrauma and Decompression Sickness
Barotrauma is any of several injuries arising from changes in pressure upon the body. Humans are adapted to live at an atmospheric pressure of 760 mm of mercury (the pressure at sea level), which differs from pressures experienced
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Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). and these dissolved gases come 190 . A fatal form of barotrauma can occur in submariners and divers. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent.7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. Pilots of unpressurized aircraft. At atmospheric pressure the body tissues contain. however. underwater divers. 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. such as the ears. In certain cavities of the body. or under the skin of the neck. When a pilot ascends to a higher altitude. and intestines. there are air pockets that either expand or contract in response to changes in pressure. sinuses. and torso. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. face. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. the external pressures upon his or her body decrease. 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. sudden expansion of air trapped within the thorax can burst one or both lungs. in solution. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. small amounts of the gases that are present in the air. such as the eardrum. the pleural spaces. lungs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. due to the emergence of resistant organisms. the arterioles. In countries such as the United States.7 Approaches to Respiratory Evaluation and Treatment 7 Drug Therapies There are many different types of drugs that may be used in the treatment of respiratory diseases. antihistamines. decongestants. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. Decongestants are sympathomimetic agents. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. and thus they are used by many people. That is. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. and antibiotics. thus reducing blood flow to the inflamed areas. decongestants and antihistamines are available over the counter. veins. they mimic the effects of stimulation of the sympathetic 211 . The relative safety and efficacy of these drugs has made them generally reliable medications. However. there are three groups. When administered in nasal sprays or drops or in devices for inhalation. that are of particular importance in the routine treatment of respiratory illness. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. although capillaries. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. and larger arteries respond to some degree. The constricting action chiefly affects the smallest arteries.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

111 Adam’s apple. 100–102. 107. 34–35 amantadine. 137. 135. 94. 184 Actinomyces. 171–173 asphyxiation. 230 . 189–192. 97. 187 anesthesia. 187 byssinosis. 102. 197. 99–100. 75. 28–29 bronchiectasis. 79–80. 176. 181. Jules. 175. 175. 136. 118–119 air–blood barrier. Josef. 108. 174–175 C cancer. 168–169. 46. 169. 160–164. 169. 46. 39 alcoholism. 193 anthracosis. 173. 27 adenosine triphosphate (ATP). 197 bronchopulmonary dysplasia. 96. 213 atelectasis. 159. 86. 169 lung. 122. structure of. 81. 52. 217 Bert. 188 bird fancier’s lung. 171 AIDS. 35. 172. 171. 106 bradykinin. 73. 218–220 asbestos. 164. 168. 50 Breuer. 124–125. 30.130–131. 77 Agricola. 85 artificial respiration. 141–144 B barotrauma. structure and function of. 93. 198. 51. 182. 38. 134. 103 anemia. 123. 111. 153. 169. 194 asthma. 33–34 bronchiolitis. 30. 116. 198 bronchioles. 91. 184. 92. 127. 184–186 altitude sickness. 103. 127. 109. 211. 152. 209 animals. 152. 188–189 alveoli. 131–133. 33–34 stem. 223 bronchitis. 211. 42. 147. 159. Paul. 208. 221 asbestosis. 129. 117. 171–173. 174 Buerger disease. 186. 74. 111. 126 arterial gas embolism. structure of. 217 bronchoscopy.INDEX A acid–base balance. 114. Georgius. 81. 214 antihistamines. 64. 196. 166 black lung. 131. structure and function of. 152–156. 115. 30. 75 acidosis. 212–214 aortic body. 170–171 Bordet. 52. 112–113. 171 antibiotics. 76. 210. 137. 48 apnea. 205–208 brown lung. 49 bronchi. 113 alkalosis. 110.

215. 97. 66. 132 types of. 122. 122. 183. 88 corticosteroids. abnormal. 183 hay fever. 95. 84. 143. 158. 47. 193–195. 135. 112. 44. 117. 130. 197. 46. 223 eosinophilic granuloma. 187. 151 D decompression sickness. 69. 216–217 Hering. 87. 75–78. 166 fungi. 145. 168. 220. 52 Cheyne-Stokes breathing. common. 106. 213 hemoglobin. 108. 72 diphtheria. 156. 92. 78. 86. 184. 74 goblet cells. 63. 201. 106 glycolysis. 175. John Scott. 210. 197. 25. 211. 21. 115. 94. 190 histamine. 48. 138. 65. 91. 197–198 H Haldane. 157–158. 81 central nervous system disease. 25. 133–136. 95. 159. 198. 69–72 Gengou. 150 epiglottis. 207 physiology of. 144. 137. 145–148. 98. 49 Hering-Breuer reflex. 204. 183. 130. 64. 213 cause of. 130. 182. 65. 106. 119 231 . 187. 81. 132. 105–106. 221. 51–52. 174. 102. 209. 75. 62. 217 Clara cells. 137. 160 HIV. 131. 164. 171. 79–81. 188–189. 27. 158 diffusion limitation. 122. 191–193 drowning. 56.7 Index 181. 156–158. 96. 78. 196. 50. 80. 47. 190. 177. 98–99 epiglottitis. 58–59. 222 decongestants. 30. 180. 161. 201 F farmer’s lung. 212 exercise (training). 196–197. 136. 84. 136–138. 88–91. 199. 147. 223 7 E emphysema. 149. 49 high altitudes. 170. 34 cold. 190. 159. Octave. 47. 98–99 cystic fibrosis. 81–86. 87. 111. 80. 50. 192. 60. 67 chronic obstructive pulmonary disease (COPD). 129. 52 chloride shift. 221 cardiopulmonary resuscitation (CPR). 30 Goodpasture syndrome. 186. 189–192. 93. 50. 94. 211–212 diaphragm. 85. 215 carotid body. 98. 67. 218 dyspnea. 98–99 epinephrine. Ewald. 182 G gas exchange. 98. 64. 215. 127–129. 164 coughing blood. 214 diving. 198 croup. 137.

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

198 pneumoconiosis. 92–94. 211. 22. 41. 125. 88 rimantadine. 160 sleep. 137 oxygen therapy. 57. 23–24 sinus. 164 inflammation of. 34 pyothorax. 214–218 128. 50. 84. 22 irrigation of. 91. 118 prostaglandins. 36. 126 pleura. 180. 187 rheumatic fever. 95 shunting. 107 penicillin. 168–169. 198. 92. 214 pharynx. 220 pneumothorax. 104–105 respiratory distress syndrome. 85. 114. 128 R Relenza. 110 pulmonary alveolar proteinosis. 127–129. 87. 208.Wilhelm Conrad. 21–24. 114 Pott disease. 117. 209. 103 Röntgen. 189. 47 vagus. 127. 69–71 silicosis. 50 nitrogen narcosis. 93 congestion of. 180–182 pons. 126–130. 184. 138. 33. 103. 85 nose cilia. 87. 170. 100 rhinoviruses. 150–151 pulmonary edema. 172. 107–108. 220 pleurisy. 104 osteoporosis. 91. 45. 167. 128. 211. 26. 93. 198 pleural effusion. 108–113. 91. 127. 50 psittacosis. 126. 141. 136. 139. 152. 111 parrot fever. 126 oseltamivir. 103. 113. 149–150. 88. 99 Index 7 O obesity. 106. 130. 105–106. 93 sinusitis. 38. 56. 154. 107. 173. 95. 122. 108. 198. 223 scarlet fever. 131. 221 pollution. 92. 91–92. 179 rheumatoid arthritis. 139.7 olfactory. 87. 194 pulmonary parenchyma. 124. 19. 126. 203 P parasites. 107. 44 Pontiac fever. 94. 137. 169–170 sinuses. 179–180 Reynaud disease. 108. 214. 129–130. 164 pharyngitis. 155. 52–53. 53. S sarcoidosis. 214 pertussis. 170 pneumonia. 103. 200. structure and function of. 208. 159. 122 function of. 31–32. 89 structure and function of. 24–25 pickwickian syndrome. 136 233 . 33. 178. 146.

109. 33. 163. 123. 92. 103. 78. 176. 175. 153. 102. false. 146 strep throat. 164. 183. 92. 171. 95 tuberculosis. 97. 94 staphylococci. 99. 125.7 The Respiratory System 7 smallpox. 170. 143. 93. 21. 95. 53. 182. 138. 96. 103. 208. 214 surgery. 178. 91. 97 V vaccination. 192–193 tonsillitis. 56. 53. 197. 97 trachea. 28–30 tracheitis. 27–28 vitamin C. 164 snoring. 220–221 thoracic emphyema. 69 vestibular folds. 118. 220 typhoid. 88. 138. 173 Valsalva maneuver. 124 W whooping cough. 127–129 thoracic squeeze. 155–156. 92. 92 streptococcal bacteria. 81–86 syphilis. 97. 95. 209 swimming. 114–121. 58 ventilation–blood flow imbalance. 94 smoking. 91 vocal chords. 150. 92. 164. 171. 106. 97. 110. 116. 94–95 tonsils. 111. 91. 27–28 T Tamiflu. 94–95. 122. 87. 122. 95. 129. 123–124 sore throat. 131–132. 96–98 trench mouth. 204. 133–135. 199. 105–107 Z zanamivir. 106 thoracentesis. 91. 94. 104 tetanus. 97. 92. 107. 128. 138. 87. 23–24. 99. 199. 198. 25. 136. 172. 96.102. 93. 87. 130. 137. 218 sneezing. 103. 108. 97 smell. structure and function of. 119. 152. 130. 104–105 234 .

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