Rogers. 196. 122. All rights reserved. Biomedical Sciences Rosen Educational Services Heather M. Levy: Executive Editor J. QP121. 228. Distributed exclusively by Rosen Educational Services. Inc.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager.(The human body) “In association with Britannica Educational Publishing. p. LLC.) in association with Rosen Educational Services. Encyclopædia Britannica. © www. Inc. LLC 29 East 21st Street. Luebering: Senior Manager Marilyn L. Inc. Production Control Steven Bosco: Director. -. All rights reserved. call toll free (800) 237-9932.2—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. New York. Media Acquisition Kara Rogers: Senior Editor. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer.E. Respiratory organs—Popular works. 226. cm. Copyright © 2011 Encyclopædia Britannica. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. Barton: Senior Coordinator. Britannica.istockphoto. 159. Chip Somodevilla/Getty Images On pages 19. © www. Editorial Technologies Lisa S. Kara. ISBN 978-1-61530-147-8 (library binding) 1. I.” Includes bibliographical references and index.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. First Edition Britannica Educational Publishing Michael I. NY 10010.com / nicoolay
. For a listing of additional Britannica Educational Publishing titles. Rosen Educational Services. and the Thistle logo are registered trademarks of Encyclopædia Britannica. 230: A healthy set of lungs is the powerhouse behind the respiratory system.R467 2011 612. 60. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. 87. 41.istockphoto.
Lymphatic Vessels. and Nerves 36 Lung Development 38 Chapter 2: Control and Mechanics of Breathing 41 Control of Breathing 41 Central Organization of Respiratory Neurons 44 Chemoreceptors 46 Peripheral Chemoreceptors 46 Central Chemoreceptors 48 Muscle and Lung Receptors 49 Variations in Breathing 50 Exercise 51 Sleep 52
Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels.
and 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
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
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
Glossary 226 Bibliography 228 Index 230
The clean air then travels into the deep tissues of the lungs. The right lung has 10 airway segments. However. After passing through the larynx. They pump vital oxygen through airways and into the bloodstream every second of every day. Here. A thin membranous sac known as the pleura covers the lungs. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. eventually reaching the region where gas is exchanged. the cone-shaped passageway leading from the mouth and nose to the larynx. humans could not survive on Earth. The larynx is a hollow tube connected to the top of the windpipe. also known as the windpipe. It also sheds light on how easily a healthy respiratory system can be damaged. But there are many treatments to keep the airways free and clear. Inside the lungs. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. whether by a viral or bacterial infection or through detrimental habits such as smoking. or throat. The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. Without this ability. the most prominent feature of the lung interior are the many small air passages called
. This structure provides humans with the sense of smell while also filtering. Air that passes through the nose travels to the pharynx. the air is cleansed and moistened before entering the lungs. there are numerous nerves and blood vessels. This book explains the science behind the amazing human respiratory system. air travels through the trachea. and the left lung has 8 to 10. and moistening inhaled air.7
he human lungs are amazing feats of nature. the centre of the respiratory system. or voice box. warming. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart.
Lungs also have two distinct blood circulation systems. thereby delivering oxygen and other nutrients to organs distant from the lungs. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the
. and to the left atrium of the heart. The gas-exchange area. through the pulmonary arteries.12 inch) to less than 1 mm (less than 0. which makes exchanging gases easier. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. through the pulmonary veins. is made up of three separate compartments for blood. comprises the network of blood vessels supporting the conducting airways themselves. which range in diameter from 3 mm (0. From the heart. but still keeps them separate. or respiration. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. humans and other animals do not need to actively think about breathing in order for it to happen. air. The second blood system in the lungs. controlled by the brain. the region where oxygen is transferred to the blood and carbon dioxide is removed. The first of these. which look like cells in a honeycomb. the bronchial circulation. is an automatic process. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. The tissue compartment supports the air and blood compartments and lets them come into close contact.04 inch). The act of breathing. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs. and tissue. The average adult lung has approximately 300 million alveoli. The bronchial circulation is a vital source of nourishment for the lung tissues. the pulmonary system. Thus.7
The Respiratory System
bronchioles. the oxygenated blood is pumped to the rest of the body.
In the basic mechanics of breathing. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. there also exist sensors that monitor the muscles that control breathing. During exercise.7 Introduction
abdomen. In addition to the types of sensors described above. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. during sleep. others respond to chemical changes in the immediate external environment. metabolic rate slows and therefore respiration rate decreases and oxygen demand is low. which functions to move air in and out of the lungs as it contracts and relaxes. One of the major abdominal muscles involved in breathing is the diaphragm. metabolic rate and acid levels in muscle tissue increase. Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. This response represents the body’s attempt to prevent toxins from entering the lungs. These effects trigger an increase in respiration rate. The
. When stimulated. thereby increasing oxygen delivery to tissues and maintaining the body’s acid–base balance. In contrast. respectively. these receptors constrict the airways and cause breathing to become fast and shallow. air moves in and out of the lungs in response to pressure changes. which are located throughout the body. One of the most notable features of respiratory control is the way in which neural communication between the body and the brain fine-tunes the rate of breathing in order to keep carbon dioxide pressure in the blood constant. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors.
can cause the brain and the heart to stop functioning. At high altitudes. In adults. transfer carbon dioxide from and add oxygen to blood. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. Oxygen deprivation. This exchange of gases takes place over an immense surface area. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. acclimatization. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. However. The amount of air that the lungs pump changes dramatically depending on external or internal conditions. during vigorous breathing.7 The Respiratory System
diaphragm is the major muscle that facilitates breathing. even for only a few minutes. Without oxygen. The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. The main purpose of respiration is to provide oxygen for the body’s cells. Oxygen is used by cells for the breakdown of nutrients. Respiration. circulation. but it is assisted by a complex assembly of other muscle groups. hiking up during the day and descending down to camp to
. cells are unable to function properly. in which the body works to more efficiently utilize oxygen in the air. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. The pulmonary alveoli. 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 small air spaces in the lungs. an activity that is necessary to supply energy to the cells and the body. and metabolism all work together. is a gradual process. People who live at high altitudes adapt to this decrease in oxygen availability. which can lead to death.
which can be particularly dangerous in infants and in the elderly. The
. If these precautions are not taken. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. it was a leading cause of death. Inflammation of respiratory tissues can sometimes be severe and chronic. For example. which can arise as a result of infection. Other common upper respiratory conditions include sore throat and pharyngitis. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. in which the body circulates additional blood to the lungs. pneumonia was a widespread and notoriously deadly disease. This enables the body to adjust to the decreased availability of oxygen. Before antibiotics were widely available.7 Introduction
sleep at night. as climbers make their way up the mountain. Pneumonia also often affects persons with impaired immune systems. In the lower respiratory system. as well as bacterial pneumonia. Essentially. because these individuals are unable to defend against infectious organisms. but the blood leaks into the air sacs. bacteria can cause inflammation of the trachea. certain viruses and fungi can also cause the disease. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. Although bacteria sometimes cause pneumonia. which can lead to high-altitude pulmonary edema. death is caused by drowning. Tuberculosis is another example of a respiratory disease caused by bacteria. and in the first decade of the 21st century. In the 18th and 19th centuries. the body’s tissues become deprived of oxygen. many people have their tonsils removed after suffering from chronic tonsillitis. a condition known as tracheitis.
Eventually.” and thus is used to describe diseases of uncertain origin. The term idiopathic means “of unknown cause. Infection is accompanied by fever. Influenza is a common. Some respiratory diseases are inherited. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. blood vessels in the lungs burst. headaches. One of the deadliest influenza pandemics was that of 1918–19. resulting in the formation of cavities in the lungs.7
The Respiratory System
tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). One example is idiopathic pulmonary fibrosis. snoring is caused by blocked airways. Lung cancer can arise as a result of a
. muscle pains. no cause has been identified. A severe form of snoring is sleep apnea. A respiratory disease of major concern in the world today is lung cancer. and the infected person coughs up bright red blood. which caused between 25 million and 50 million deaths worldwide. seasonal respiratory illness that is caused by viral infection. sticky mucus that blocks the airways and the digestive tract. which may be associated with obesity. For some diseases of the respiratory system. to form. in which the collapse of the airways leads to intermittent stoppages in breathing. a strain of influenza virus gives rise to a pandemic. which results in progressive shortness of breath until a person can no longer breathe. Many respiratory conditions arise from noninfectious causes. or large cheese-like masses. despite extensive research. One of the best-characterized inherited conditions is cystic fibrosis. It is a highly contagious disease too. Sleep apnea causes affected individuals to awaken periodically through the night. For example. the primary symptom of which is the production of a thick. Every few decades. This process leads to the eventual breakdown of respiratory tissues. and stomach pain. chills.
have been around for years and are readily available. or work. resulting in an estimated 1. however.3 million fatalities each year. which affects coal miners who inhale coal dust for many years. Breathing asbestos can also cause the cancerous condition known as mesothelioma. In addition to vaccines and antivirals. Nasal decongestants and antihistamines are examples of commonly used remedies. Some respiratory diseases arise as a result of occupational. Several vaccines have been developed to prevent illnesses such as influenza. and even cockroaches. or white lung disease. however. Breathing problems caused by allergies to environmental conditions are fairly common. Doctors first described the symptoms of lung cancer in the mid-19th century. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. factors. particularly pneumonia and tuberculosis. more than 7 percent of children and 9 percent of adults suffer from asthma. tobacco smoke. The best-known occupational lung disease is black lung. In the early 20th century.
. lung cancer is the leading cause of cancer deaths worldwide. Scientists are constantly researching and developing new and different treatments for respiratory ailments. most likely resulting from exposure to air pollution. Construction workers and insulators exposed to asbestos often suffer from asbestosis. Now. although tobacco smoking is the primary cause. 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. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria.7 Introduction
variety of factors. Today. Many treatments. There is hope for those who suffer from respiratory diseases and disorders. it was still considered rare.
The Respiratory System
Lung cancer treatments may consist of surgery. and radiation. and the consequences of neglecting or damaging that fragile system can be drastic.
. chemotherapy. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant. Treatment may also be based on the results of genetic screening. A healthy set of lungs is nothing to take for granted. the human respiratory system is a finely tuned feat of engineering. which can identify mutations that render some lung cancers susceptible to certain drugs. As this book shows. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place.
it is otherwise an automatic process. the lung. The upper airway system comprises the nose and the paranasal cavities (or sinuses). the bronchioles. as simple as it is for us to inhale and exhale. Breathing. and though we possess the ability to consciously control the rate of our breathing. The lower airway system consists of the larynx. occurring without our having to think about it.CHAPTER1
ANATOMY AND FUNCTION OF THE HUMAN RESPIRATORY SYSTEM
ur respiratory system provides us with the fundamental ability to breathe: to inhale and exhale air from our lungs. The respiratory system consists of two divisions: upper airways and lower airways. the pharynx (or throat). supporting this process are a number of complex actions that occur within our bodies. These actions encompass not only muscular movements but also cellular and chemical processes. where its delicate tissues are
. just at the top of the larynx (or voice box). and the alveolar ducts. and all the airways that branch extensively within the lungs. the trachea. is fundamental to survival. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. and part of the oral cavity. or respiration. such as the intrapulmonary bronchi.
the design of the respiratory systeM
The human gas–exchanging organ. Yet. is located in the thorax (or chest). the stem bronchi.
7 The Respiratory System
The lungs serve as the gas-exchanging organ for the process of respiration.
protected by the bony and muscular thoracic cage. called conducting airways. carbon dioxide. Atmospheric air is pumped in and out regularly through a system of pipes. Encyclopædia Britannica. Inc. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product.
such as enabling the sensation of smell. is sometimes also considered a part of the upper airways. For respiration.e. The oral cavity.
Morphology of the upper airways
The nose. The muscles expand and contract the internal space of the thorax.. through which air may be inhaled or exhaled. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall.
The nose is the external protuberance of an internal space. and the circulatory system (i. the nasal
. the nasal cavity. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract.7
Anatomy and Function of the Human Respiratory System
which connect the gas–exchange region inside the body with the environment outside the body. which acts as a carrier of gases. In addition to fulfilling a fundamental role in respiration. Other elements fundamental to the process of respiration include the blood. and it protects against the passage into the lungs of potentially infectious foreign agents. as the main respiratory muscle. The filtering process is vital to clearing inhaled air of dust and other debris. sinuses. the collaboration of other organ systems is essential. the structures of the upper respiratory tract also have other important functions. and the intercostal muscles of the chest wall play an essential role by generating. which pumps blood from the heart to the lungs and the rest of the body. The diaphragm. the heart and the blood vessels). under the control of the central nervous system. whose bony framework is formed by the ribs and the thoracic vertebrae. the pumping action on the lung.
This structural design
. Typically. they are called the maxillary sinus. they help keep the weight of the skull within reasonable limits. and sphenoid bones. ciliated and secreting cells. Correspondingly. Each canal opens to the face by a nostril and into the pharynx by the choana. it is also flooding the nasal cavity. middle. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. The floor of the nasal cavity is formed by the palate. the ethmoid sinuses. which also forms the roof of the oral cavity. Most of their development takes place after birth. and inferior turbinate bones (or conchae). The passageways thus formed below each ridge are called the superior. which is located in the upper posterior wall of the nasal cavity. with the lacrimal apparatus in the corner of the eye. via the nasolacrimal duct. and they serve as resonance chambers for the human voice. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. and the sphenoid sinus. The sinuses are located in four different skull bones: the maxilla. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also.7
The Respiratory System
septum. and they reach their final size around age 20. the superior. The complex shape of the nasal cavity results from projections of bony ridges. the mucosa of the nose contains mucus-secreting glands and venous plexuses. On each side. and inferior nasal meatuses. consists principally of two cell types. from the lateral wall. the frontal sinus. The sinuses have two principal functions: because they are filled with air. middle. The duct drains the lacrimal fluid into the nasal cavity. ethmoid. The paranasal sinuses are sets of paired single or multiple cavities of variable size. the epithelium. frontal. which is the largest cavity. Its top cell layer.
the olfactory organ with its sensory epithelium checks the quality of the inspired air. They clean. the air is dried and cooled. About two dozen olfactory nerves convey the sensation of smell from the
. During expiration through the nose. The vestibule. In the roof of the nose.
reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. preparing it for intimate contact with the delicate tissues of the gas-exchange area. and warm the inspired air. a process that saves water and energy. is lined by skin that bears short thick hairs called vibrissae. moisten. Inc. at the entrance of the nose. Two regions of the nasal cavity have a different lining. Encyclopædia Britannica.7
Anatomy and Function of the Human Respiratory System
Sagittal view of the human nasal cavity.
The upper floor. 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. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. Encyclopædia Britannica.
For the anatomical description. the nasopharynx. 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. the pharynx can be divided into three floors.7 The Respiratory System
olfactory cells through the bony roof of the nasal cavity to the central nervous system.
it may interfere with nasal respiration and alter the resonance pattern of the voice. and food from the oral cavity is routed to the esophagus directly behind the larynx. the vessels transporting blood between the heart and the lungs. The cavity is enclosed by the ribs. the vertebral column. The lungs reside within the thoracic cavity (chest cavity). which roofs the posterior part of the oral 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 middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx. The lower floor of the pharynx is called the hypopharynx. while the lungs themselves receive the air and facilitate the process of gas exchange. Its anterior wall is formed by the posterior part of the tongue.7
Anatomy and Function of the Human Respiratory System
nasopharynx is located a lymphatic organ. and lungs. controls the traffic of air and food. It is delimited from the nasopharynx by the soft palate. The first two of these provide a canal for the passage of air to the lungs. leafshaped flap. The epiglottis. When it is enlarged (as in tonsil hypertrophy). Lying directly above the larynx. the diaphragm. trachea.
. Also residing within the thoracic cavity is the tracheobronchial tree: the heart.
Morphology of the lower airways
The major structures of the lower airways include the larynx. a cartilaginous. during the act of swallowing. 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. the great arteries bringing blood from the heart out into general circulation. the pharyngeal tonsil. which is the second–largest hollow space of the body.
Sound is produced by forcing air through a sagittal slit formed by the vocal cords. The membrane continues over the lung. when it occurs. so called because it exudes a thin fluid. The pleural cavity is the space. The chest cavity is lined with a serous membrane.7
The Respiratory System
and the major veins into which the blood is collected for transport back to the heart. For the precise function of the muscular apparatus. This causes not only the vocal cords but also the column of air above them to vibrate. The laryngeal skeleton consists of almost a dozen pieces of cartilage. The largest cartilage of the larynx. or serum.
The larynx is an organ of complex structure that serves a dual function: as an air canal to the lungs and a controller of its access. the glottis. between the parietal and the visceral pleura. Control is achieved by a number of muscles innervated by the laryngeal nerves. most of them minute. the two surfaces tend to touch. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. the thyroid cartilage. where it is called the visceral pleura. and the great vessels. the heart. and over part of the esophagus. As evidenced by trained singers. the mediastinum being the space and the tissues and structures between the two lungs. interconnected by ligaments and membranes. This portion of the chest membrane is called the parietal pleura. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. the muscles must be anchored to a stabilizing framework. is made of two plates fused
. as the mediastinal pleura. and as the organ of phonation. this function can be closely controlled and finely tuned.
The cricoid is located below the thyroid cartilage. to which it is joined in an articulation reinforced by ligaments. Because the arytenoid cartilages rest upright on the cricoid plate. the arytenoid cartilages. The cricoid. made of elastic tissue. Just above the vocal cords. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. they are also formed by the free end
. the lumen of the laryngeal tube has an hourglass shape. At the upper end of the fusion line is an incision. with its narrowest width at the glottis. Behind the shieldlike thyroid cartilage. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. 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. Viewed frontally. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. the epiglottis is also attached to the back of the thyroid plate by its stalk. they follow its tilting movement. the laryngeal prominence. has a signet-ring shape. resembling an organ pipe. The vocal ligaments are part of a tube. 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. Like the true vocal cords. below it is a forward projection. the vocal cords span the laryngeal lumen. This mechanism plays an important role in altering length and tension of the vocal cords. which has given this structure the common name of Adam’s apple.7
Anatomy and Function of the Human Respiratory System
anteriorly in the midline. The transverse axis of the joint allows a hingelike rotation between the two cartilages. another large cartilaginous piece of the laryngeal skeleton. the thyroid notch.
8 inch) wide. one each for the left and right lung. and tension of the vocal cords. Between the vestibular folds and the vocal cords. The interior of the trachea is lined by the typical respiratory epithelium. the trachea divides in an inverted Y into the two stem (or main) bronchi. the latter can easily be seen from above with the laryngoscope. Because the gap between the vestibular folds is always larger than the gap between the vocal cords.. The muscular apparatus of the larynx comprises two functionally distinct groups.g. The extrinsic muscles act on the larynx as a whole.
The Trachea and the Stem Bronchi
Below the larynx lies the trachea. the laryngeal space enlarges and forms lateral pockets extending upward. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. This space is called the ventricle of the larynx. an instrument designed for visual inspection of the interior of the larynx. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. At its lower end. length. The intrinsic muscles attach to the skeletal components of the larynx itself. The intrinsic muscles act directly or indirectly on the shape. is oriented more vertically. during high-pitched phonation or swallowing) or downward. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. and is shorter than the left main bronchus. moving it upward (e. The right main bronchus has a larger diameter. The mucosal layer contains mucous glands. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum.7
The Respiratory System
of a fibroelastic membrane. The practical consequence of
and a transitional zone in between. Individual paths. Functionally. In irregular dichotomy. purely conducting zone. it is generally agreed that the airways branch according to the rules of irregular dichotomy. it makes sense to distinguish the relatively thick-walled. purely gas-exchanging zone. and partly also of the blood vessels penetrating the lung. In modeling the human airway tree. largely determines the internal lung structure. where both functions grade into one another. From a morphological point of view. a peripheral. the intrapulmonary airway system can be subdivided into three zones: a proximal. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. The structure of the stem bronchi closely matches that of the trachea. however. if the trachea is counted as generation zero. however.
. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition.7
Anatomy and Function of the Human Respiratory System
this arrangement is that foreign bodies passing beyond the larynx will usually slip into the right lung.
structural design of the airway tree
The hierarchy of the dividing airways. the daughter branches may differ greatly in length and diameter. however. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. may range from 11 to 30 generations. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions.
In larger airways. After several generations of such respiratory bronchioles. within which the cilia exert a synchronized. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. their height decreasing with the narrowing of the tubes. gain their stability from their structural integration into the gas-exchanging tissues. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. In the alveoli. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. the alveoli are so densely packed along the airway that an airway wall
. Their function is to further warm. This design can be compared to a conveyor belt for particles. the walls of the bronchioles. devoid of cartilage. Distally. the two stem bronchi. Ciliated cells are present far down in the airway tree. this fluid layer is topped by a blanket of mucus of high viscosity. where they are swallowed. and indeed the mechanism is referred to as the mucociliary escalator. the bronchi. and the bronchioles. moisten. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. The epithelium is covered by a layer of low-viscosity fluid. as does the frequency of goblet cells. The last purely conductive airway generations in the lung are the terminal bronchioles. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. rhythmic beat directed outward.7
The Respiratory System
The conducting airways comprise the trachea.
The right and left lungs are slightly unequal in size. major blood vessels.
Humans have two lung organs. and nerves enter or leave the lungs. and the thymus gland. the two lungs rest with their bases on the diaphragm. The right lung represents 56 percent of the total lung volume and is composed of three lobes. blood and lymphatic vessels. a superior. the esophagus. a circumscribed area where airways. smaller in volume because of the asymmetrical position of the heart. The parietal pleura and the visceral pleura that line the inside
. middle. while their apexes extend above the first rib. The space between them is filled by the mediastinum. a right and a left. has only two lobes separated by an oblique fissure. In the thorax. and the airway consists of alveolar ducts. they are connected with the mediastinum at the hilum. and inferior lobe. the lungs occupy most of the intrathoracic space. the trachea with the stem bronchi.
Together. Medially. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. which corresponds to a connective tissue space containing the heart.7
Anatomy and Function of the Human Respiratory System
proper is missing. The final generations of the airway tree end blindly in the alveolar sacs. separated from each other by a deep horizontal and an oblique fissure. In humans each lung is encased in a thin membranous sac called the pleura. The left lung.
Although the hilum is the only place where the lungs are secured to surrounding structures. The presence of pleural recesses form a kind of reserve space. so the pleural cavity is larger than the lung volume. the parietal pleura can be subdivided into three portions: mediastinal.7 The Respiratory System
Anatomy of the human lungs. thus allowing the lung to increase in volume. costal. are in direct continuity at the hilum. respectively. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. the recesses are partly opened by the expanding lung. and diaphragmatic pleurae. Encyclopædia Britannica.
of the thoracic cavities and the lung surface. Depending on the subjacent structures. During inspiration. Inc. A thin film of extracellular fluid between the pleurae enables
If the serous membranes become inflamed (pleurisy). Furthermore. Bronchioles are
. the lung immediately collapses owing to its inherent elastic properties. There are 10 segments in the right lung and 8 to 10 segments in the left lung. Unlike the lobes. and breathing is abolished on this side. besides lymphatics and nerves. respiratory movements can be painful. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic.
The Bronchi and Bronchioles
In the intrapulmonary bronchi. This outer fibrous layer contains. depending on the classification. The bronchi are ensheathed by a layer of loose connective tissue that is continuous with the other connective tissue elements of the lung and hence is part of the fibrous skeleton spanning the lung from the hilum to the pleural sac. the 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. the arterial supply follows the segmental bronchi. the pulmonary segments.7
Anatomy and Function of the Human Respiratory System
the lungs to move smoothly along the walls of the cavity during breathing. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation.
The lung lobes are subdivided into smaller units. and the surgeon can remove single diseased segments instead of whole lobes. If air enters a pleural cavity (pneumothorax).
722 square feet) of internal surface area of the tissue compartment. They are polyhedral structures. Distally. in the last generation. an adult human lung has about 300 million alveoli. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. The walls of the bronchioles lack cartilage and seromucous glands. with a
. alveolar sacs.7
The Respiratory System
small conducting airways ranging in diameter from three to less than one millimetre. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. and non-capillary blood vessels belong to the non-parenchyma. capable of narrowing the airway. which produce secretions. the whole wall is formed by alveoli. Whereas air and blood are continuously replenished. while the supplying structures. until after two to four generations of respiratory bronchioles. On average. The respiratory gases diffuse from air to blood.
The Gas-Exchange Region
The gas-exchange region comprises three compartments: air. blood. The gas-exchange tissue proper is called the pulmonary parenchyma. lymphatics. conductive airways. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells. The airways are then called alveolar ducts and. and tissue. through the 160 square metres (about 1. and vice versa. the frequency of alveolar outpocketings increases rapidly.
the smallest of the blood vessels. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing. the thin air–blood barrier for gas exchange. a second. squamous cell type. the alveolar macrophages are derived from the bone marrow. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. is common to two adjacent alveoli. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. partly foreign material that may have reached the alveoli. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. and their cell bodies abound in granules of various content. covers the remaining surface. It contains a dense network of capillaries. It contains connective tissue and interstitial
. and their task is to keep the air–blood barrier clean and unobstructed. more cuboidal cell type. Ultimately.7
Anatomy and Function of the Human Respiratory System
diameter of about 250 to 300 micrometres. The interalveolar septum is covered on both sides by the alveolar epithelial cells. or cell debris originating from cell damage or normal cell death. These granules are the conspicuous ultrastructural features of this cell type. together with the endothelial cells. They are large cells. The alveolar wall. the type I pneumocyte. the pulmonary surfactant. and a skeleton of connective tissue fibres. the type II pneumocyte. The type I cells form. alveolar macrophages creep around within the surfactant fluid. On top of the epithelium. A thin. and open on one side. covers between 92 and 95 percent of the gas-exchange surface. whereas type II cells are secretory. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. where they connect to the airway. Type II pneumocytes produce a surface-tension-reducing material. Before it is released into the airspaces. called the interalveolar septum.
the pulmonary arteries. This pathological condition is called pulmonary edema.7
The Respiratory System
fluid. to prevent the accumulation of extracellular fluid in the interalveolar septa. the respiratory gases must diffuse across longer distances. Lymphatic Vessels. On each side.
Blood Vessels. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. which seem to be endowed with contractile properties. The oxygenated blood from the capillaries is collected by
. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. are much flimsier than systemic arteries of corresponding size. the lung is a complex organ. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. alternatively. and Nerves
With respect to blood circulation. Because intravascular pressure determines the arterial wall structure. and proper functioning of the lung is severely jeopardized. low in oxygen content but laden with carbon dioxide. After numerous divisions. and cells (mainly fibroblasts). which have on average a pressure five times lower than systemic arteries. an excess of fluid accumulates in the lung tissue and within the airspaces. following relatively closely the course of the dividing airway tree. The fibroblasts are thought to control capillary blood flow or. As a consequence. amorphous ground substance. is carried from the right heart through the pulmonary arteries to the lungs. Blood. The connective tissue comprises a system of fibres.
Within the lung and the mediastinum. they end several generations short of the terminal bronchioles.7
Anatomy and Function of the Human Respiratory System
venules and drained into small veins. 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. called bronchomediastinal trunks. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. Small bronchial veins exist. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. Finally. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. Lymph drainage
. They are small vessels and generally do not reach as far into the periphery as the conducting airways. Most of their blood is naturally collected by pulmonary veins. Generally. however. With a few exceptions. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. The bronchial arteries originate from the aorta or from an intercostal artery. The interlobular veins then converge on the intersegmental septa. The superficial.
The Respiratory System
paths from the lung are complex. The precise knowledge of their course is clinically relevant, because malignant tumours of the lung spread via the lymphatics. The pleurae, the airways, and the vessels are innervated by afferent and efferent fibres of the autonomic nervous system. Parasympathetic nerve fibres from the vagus nerve (10th cranial nerve) and sympathetic branches of the sympathetic nerve trunk meet around the stem bronchi to form the pulmonary autonomic nerve plexus, which penetrates into the lung along the bronchial and vascular walls. The sympathetic fibres mediate a vasoconstrictive action in the pulmonary vascular bed and a secretomotor activity in the bronchial glands. The parasympathetic fibres stimulate bronchial constriction. Afferent fibres to the vagus nerve transmit information from stretch receptors, and those to the sympathetic centres carry sensory information (e.g., pain) from the bronchial mucosa.
After early embryogenesis, during which the lung primordium is laid down, the developing human lung undergoes four consecutive stages of development, ending after birth. The names of the stages describe the actual morphology of the prospective airways. The pseudoglandular stage exists from 5 to 17 weeks; the canalicular stage, from 16 to 26 weeks; the saccular stage, from 24 to 38 weeks; and finally the alveolar stage, from 36 weeks of fetal age to about 1 ½ to 2 years after birth. The lung appears around the 26th day of intrauterine life as a ventral bud of the prospective esophagus. The bud separates distally from the gut, divides, and starts to grow into the surrounding mesenchyme. The epithelial components of the lung are thus derived from the gut (i.e., they
Anatomy and Function of the Human Respiratory System
are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.
The Respiratory System
The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.
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.
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
In addition. and maintaining posture. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement. such as the airway narrowing that occurs in an asthmatic attack. 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. Although the diaphragm is the major muscle of breathing. Mechanoreceptors monitor the expansion of the lung. such as speaking. 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. 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 the extent of muscle shortening. the size of the airway. chewing and swallowing.7
The Respiratory System
swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. the force of respiratory muscle contraction. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. abdominal muscles. they also complicate the regulation of breathing. Intercostal muscles inserting on the ribs. These same muscles are used to perform a number of other functions. breathing can be
. its respiratory action is assisted and augmented by a complex assembly of other muscle groups.
Control and Mechanics of Breathing
Singing demands a strong diaphragm to control breath.com
in turn they drive cranial motor neurons. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. 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. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. allowing the activity of these physiological systems to be coordinated with respiration.7
The Respiratory System
influenced by higher brain centres and even controlled voluntarily to a substantial degree. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla.
central organization of respiratory neurons
The respiratory rhythm is generated within the pons and medulla. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. 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. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. inspiration is characterized by an augmenting discharge of medullary neurons that terminates
this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. but at a much lower level. This type of breathing. offswitch. After a gap of a few milliseconds. inspiratory activity is restarted. is called apneustic breathing. When the vagus nerves are sectioned or pontine centres are destroyed. and expiratory. Then the cycle begins again. and gradually declines until the onset of expiratory neuron activity. although in upright humans the lower expiratory intercostal muscles
. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity. breathing is characterized by prolonged inspiratory activity that may last for several minutes. Mechanically. which produces lung expansion. which occasionally occurs in persons with diseases of the brain stem. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. post-inspiratory. early inspiratory. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. As the activity of the post-inspiratory neurons subsides. Offswitch neurons in the medulla terminate inspiration. 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. 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.7 Control and Mechanics of Breathing
abruptly. This increase in activity.
Hypoxia. As expiration proceeds. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. as the demand to breathe increases (for example. more expiratory intercostal and abdominal muscles contract. for example. by a
. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. or the reduction of oxygen supply to tissues to less than physiological levels (produced. There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. Moreover. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). Conversely. and central chemoreceptors in the brain. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. too much ventilation depresses the partial pressure of carbon dioxide.
One way in which breathing is controlled is through feedback by chemoreceptors. 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. 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. During sleep and anesthesia. with exercise).7
The Respiratory System
and the abdominal muscles may be active even during quiet breathing.
may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. and the carotid body senses these fluctuations. responding more to rapid than to slow changes in the partial pressure of carbon dioxide. Acetylcholine. a branch of the glossopharyngeal nerve. catecholamines. as reflected in the size of carotid body signals. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. vasoactive
. 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.7 Control and Mechanics of Breathing
trip to high altitudes). the principal arterial chemoreceptors. 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). This arterial blood parameter rises and falls as air enters and leaves the lungs. and neuropeptides such as enkephalins. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls. unlike type II cells. The type II cells are generally not believed to have a direct role in chemoreception. stimulates the carotid and aortic bodies. Fine sensory nerve fibres are found in juxtaposition to type I cells. the carotid body consists of two different types of cells. In addition to responding to hypoxia. which. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. The amplitude of these fluctuations. The type I cells are arranged in groups and are surrounded by type II cells. Microscopically. contain electron-dense vesicles.
are located within the vesicles. As the partial pressure of carbon dioxide in arterial blood rises. 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. 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. and substance P.
Carbon dioxide is one of the most powerful stimulants of breathing.7
The Respiratory System
intestinal peptide. 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. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide. Current thinking places these receptors near the undersurface (ventral part) of the
. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. 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. Even if both the carotid and aortic bodies are removed. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. ventilation increases nearly linearly. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. inhaling gases that contain carbon dioxide stimulates breathing.
Tendon organs. another receptor in muscles. which excites stretch receptors in the airways. in the respiratory muscles measure muscle length and increase motor discharge to the diaphragm and intercostal muscles when increased stiffness of the lung or resistance to the movement of air caused by disease impedes muscle shortening.
. there is a length at which the force generated is maximal. These receptors are particularly important when lung function is impaired.7 Control and Mechanics of Breathing
medulla. Some investigators argue that respiratory responses produced at the ventral medullary surface are direct and are caused by interference with excitatory and inhibitory inputs to respiration from these vasomotor neurons. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. Stimulation of these receptors. Generally. called spindles. monitor changes in the force produced by muscle contraction. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. The Hering-Breuer reflex is initiated by lung expansion. Receptors.
Muscle and Lung Receptors
Receptors in the respiratory muscles and in the lung can also affect breathing patterns. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. because they can help maintain tidal volume and ventilation at normal levels. Changes in the length of a muscle affect the force it can produce when stimulated.
The Respiratory System
which send signals to the medulla by the vagus nerve. The most important function of these receptors. the reflex allows inspiratory time to be lengthened. during exercise.
Variations in breathing
Variations in breathing result from changes in metabolic demands in the tissues of the body. At the opposite end of the spectrum. When stimulated. and thus breathing typically becomes lighter. helping to preserve tidal volume. may be to defend the lung against noxious material in the atmosphere. For example. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. increased levels of oxygen are needed to fuel muscle function. during sleep. like the stretch receptors. however. the body’s metabolic rate slows. 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. This in turn leads to fluctuations in breathing patterns. others (the J receptors) by unmyelinated fibres.
. these receptors constrict the airways and cause rapid shallow breathing. and prostaglandins. However. Stimulation of irritant receptors also causes coughing. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. bradykinin. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. When lung inflation is prevented. accelerating the frequency of breathing. shortens inspiratory times as tidal volume (the volume of air inspired) increases. These receptors are supplied. by the vagus nerve.
because body temperature rises as metabolism increases. the arterial chemoreceptors. Sources of these signals include mechanoreceptors in the exercising limbs.7 Control and Mechanics of Breathing
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.
Mechanoreceptors. arterial chemoreceptors. and thermal receptors. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide.com 51
. and thermal receptors all work in concert during exercise to enhance ventilation. thus preserving acid–base homeostasis. Shutterstock. A number of signals arise during exercise that can augment ventilation.
During sleep. Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. Changes in the concentration of potassium and lactic acid in the exercising muscles acting on unmyelinated nerve fibres may be another mechanism for stimulation of breathing during exercise. In slow-wave sleep. how these various mechanisms are adjusted to maintain acid–base balance.
During sleep. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. It remains unclear. 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. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. This rhythmic waxing and waning of breathing. but it may entail unstable feedback regulation of breathing. breathing can become quite erratic. body metabolism is reduced. however. is called Cheyne-Stokes breathing.7
The Respiratory System
The brain also seems to anticipate changes in the metabolic rate caused by exercise.
. with intermittent periods of apnea. after the physicians who first described it. breathing is diminished but remains regular. whereas in rapid eye movement sleep. The effects on ventilatory pattern vary with sleep stage. or even apnea (cessation of breathing). The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued.
leading to severe drops in the levels of blood oxygenation. flow is determined by how
. termed sleep apnea syndrome. like the tongue and laryngeal adductors. Snoring and disturbed behaviour during sleep may also occur. however. air enters the lungs (inspiration). When the air pressure within the alveoli exceeds atmospheric pressure. and the reduced activity of these muscles during sleep may lead to upper airway closure. undergo phasic changes in their electrical activity synchronous with respiration. In some persons with sleep apnea syndrome. Because arousal is often associated with the termination of episodes of obstruction. portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids.
the Mechanics of breathing
Air moves in and out of the lungs in response to differences in pressure.7 Control and Mechanics of Breathing
In addition. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. air is blown from the lungs (expiration). provided the larynx is open. this intermittent obstruction occurs repeatedly during the night. and in the obese. and complaints of excessive daytime drowsiness are common. occurs most commonly in the elderly. which increase the likelihood of obstruction. Because atmospheric pressure remains relatively constant. In some individuals. Many of the upper airway muscles. sleep is of poor quality. When the air pressure within the alveolar spaces falls below atmospheric pressure. in the newborn. in males. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways. have normal upper airway anatomy. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. Others. The condition.
Alveolar pressure fluctuations are caused by expansion and contraction of the lungs resulting from tensing and relaxing of the muscles of the chest and abdomen. less air per unit of volume in the lungs and pressure falls. Inc. the volume of chest and lungs
. Encyclopædia Britannica.7
The Respiratory System
The diaphragm contracts and relaxes.
much above or below atmospheric pressure the pressure within the lungs rises or falls. Each small increment of expansion transiently increases the space enclosing lung air. When the muscles of inspiration relax. therefore. and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume. There is. A difference in air pressure between atmosphere and lungs is created. forcing air in and out of the lungs.
7 Control and Mechanics of Breathing
decreases. therefore. In summary. the pleural pressure reflects primarily two forces:
. A lung is similar to a balloon in that it resists stretch. then. its pressure rises above atmospheric pressure. This negative (below-atmospheric) pressure is a measure. This. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. lung air becomes transiently compressed. of the force required to keep the lung distended. 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. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference.
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. resulting in flow of air into or out of the lung and establishment of a new lung volume. This tendency of the lung to collapse or pull away from the chest is measurable by carefully placing a blunt needle between the outside of the lung and the inside of the chest wall. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. thereby allowing the lung to separate from the chest at this particular spot. 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.
This additional muscular force is removed on relaxation
. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. these would collapse. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest.
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. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. The lung– chest system thus acts as two opposed coiled springs. During inspiration. thereby further raising the diaphragm and causing forceful expiration. Were it not for the outward traction of the chest on the lungs. Because the pleural pressure is below atmospheric pressure. which are in turn stretched inward by the pull of the lungs. the additional retraction of lung returns the system to its equilibrium position. When these muscles relax. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. the force required to keep the lung inflated against its elastic recoil and 2. And were it not for the inward traction of the lungs on the chest and diaphragm.7
The Respiratory System
1. as by a wound or by a surgical incision. the force required to cause airflow in and out of the lung. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch.
The volume in these circumstances is known as the residual volume. capable of increasing its output 25 times. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9.
The Respiratory Pump and Its Performance
The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. such as pieces of glass. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. separated by a film of water. Pressures
. The respiratory pump is versatile. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness.7 Control and Mechanics of Breathing
and the original lung volume is restored.154 cubic inches) per minute in adults. At total relaxation of the muscles of inspiration and expiration. During ordinary breathing. muscular contraction occurs only on inspiration. expiration being accomplished “passively” by elastic recoil of the lung.
with no space between the vocal cords). Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.com / Jason Lugo
within the lungs can be raised to 130 centimetres of water (about 1. normally reaching 30 litres per minute in quiet breathing.e. can be raised voluntarily to 400 litres per minute. Airflow velocity.7
The Respiratory System
A cough clears the airways with an abrupt opening of the larynx..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. © www . The beating of cilia (hairline projections) from cells lining the airways
. The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles.istockphoto.
and seven litres. 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. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated.
. 500 millilitres. however. In fact. totaling about 0.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. such adherence occasionally does occur and is one of the dreaded complications of premature births. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae.7 Control and Mechanics of Breathing
normally maintains a steady flow of secretions toward the nose. respectively. Normal lungs.
Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane. For inhaled oxygen to reach these tissues.722 square feet). transfer carbon dioxide to the alveoli. the respiratory system. in exchange. 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. adapt to variations in atmospheric pressure. This process of adaptation is necessary to maintain normal physiological function. or ¹/¹00 of the diameter of a human hair. about 0. however.
Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. The area of the alveolar surface in the adult human is about 160 square metres (1. as well as other organ systems. whereas the carbon dioxide is expelled from the alveoli during exhalation.5 micrometre. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and. The oxygen is then distributed by the blood to the tissues. At high altitudes or during activities such as deep-sea diving.
. which is needed to support the functions of the body’s various tissues.CHAPTER3
GAS EXCHANGE AND RESPIRATORY ADAPTATION
nhaled air is rich in oxygen.
.7 Gas Exchange and Respiratory Adaptation
Changes in the atmosphere’s pressure occur when deep-sea diving and require the respiratory system to adapt.
The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. Convection. The rapidity of circulation is determined by the output of the heart. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues. 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. or mass flow. the partial pressure of each gas is directly proportional to its concentration. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. The performance of the heart and circula-
. In a mixture of gases. 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. in the flow through skeletal muscles during exercise. Respiratory gases also move by diffusion across tissue barriers such as membranes. for example. Local flows can be increased selectively. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. which in turn is responsive to overall body requirements. The partial pressure of a gas in fluid is a measure of its tendency to leave the fluid when exposed to a gas or fluid that does not contain that gas. as occurs.7
The Respiratory System
Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. convection and diffusion. but almost equal quantities of the two gases are involved in metabolism and gas exchange. caused by differing modes of transport in the blood.
is a characteristic S-shape because binding of oxygen to one iron atom influences the ability of oxygen to bind to other iron sites. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. These systems are present mainly in the red cells. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed.
transport of oxygen
Oxygen is poorly soluble in plasma. Each iron atom can bind and then release an oxygen molecule. The curve representing the content of oxygen in blood at various partial pressures of oxygen.7
Gas Exchange and Respiratory Adaptation
tory regulation are. 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. so less than 2 percent of oxygen is transported dissolved in plasma.2 ml of oxygen per ml of blood. Not all of the oxygen transported in the blood is transferred to the tissue cells. Plasma. plays little role in oxygen exchange but is essential to carbon dioxide exchange. liquid portion of blood. In alveoli at sea level. important determinants of gas transport. The amount of oxygen
. called the oxygen-dissociation curve. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. therefore. a protein contained within red cells. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). Most oxygen is bound to hemoglobin. the cell-free.
carbon dioxide. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation).7
The Respiratory System
extracted by the cells depends on their rate of energy expenditure. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. and the oxygen-dissociation curve shifts to the right. Reductions in normal concentrations of hydrogen ions. venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. or pH. At rest. with the binding of oxygen. as occurs with anemia or extreme exercise. and 2. Although these substances do not bind to hemoglobin at the oxygen-binding sites.3-DPG result in an increased affinity of hemoglobin for oxygen. or 2.) Increases in hydrogen ions. Conversely. Because of this decreased affinity. carbon dioxide. of the blood). and 2. This reserve is available to meet increased oxygen demands. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin.3-diphosphoglycerate (2. carbon dioxide. 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.3-DPG. (Affinity denotes the tendency of molecules of different species to bind to one another. Hemoglobin binds not only to oxygen but to other substances as well.3-DPG decrease the affinity of hemoglobin for oxygen. including hydrogen ions (which determine the acidity. and the curve is shifted
About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. to form a compound known as carbamate. principally hemoglobin. Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. The range of body temperature usually encountered in humans is relatively narrow.
transport of carbon dioxide
Transport of carbon dioxide in the blood is considerably more complex. blood normally remains in the pulmonary capillaries less than a second. whereas a decrease in temperature shifts the curve to the left (increased affinity). so that temperature-associated changes in oxygen affinity have little physiological importance. The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. enhanced release of oxygen). An increase in temperature shifts the curve to the right (decreased affinity. remains unchanged and is transported dissolved in blood. The remainder is found in reversible chemical combinations in red blood cells or plasma. This displacement increases oxygen binding to hemoglobin at any given partial pressure of oxygen and is thought to be beneficial if the availability of oxygen is reduced.
. with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. about 5 percent. A small portion of carbon dioxide. Complete elimination would lead to large changes in acidity between arterial and venous blood. Some carbon dioxide binds to blood proteins. as occurs at extreme altitude. Furthermore. Temperature changes affect the oxygen-dissociation curve similarly.7
Gas Exchange and Respiratory Adaptation
to the left. an insufficient time to eliminate all carbon dioxide.
The Respiratory System
Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water. Carbonic anhydrase. Shutterstock. which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-). a relatively weak acid. essentially.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. are effective buffering agents. inactivating them. (A buffer solution resists change in acidity by combining with added hydrogen ions and. it combines with water to form carbonic acid (H2CO3 ).) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. Blood acidity is minimally affected by the released hydrogen ions because blood proteins. As carbon dioxide enters the blood. a protein enzyme present inside the
however. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. while 62 percent exists as bicarbonate in plasma. known as the chloride shift. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. Because the enzyme is present only inside the red blood cell. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. The change in molecular configuration of hemoglobin that accompanies the release of oxygen leads to increased binding of carbon dioxide to oxylabile amino groups. The simultaneous exchange of these two ions. A few amino sites on hemoglobin are oxylabile. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. that is. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. then transported to the plasma. The bulk of bicarbonate ions is first produced inside the cell.7
Gas Exchange and Respiratory Adaptation
red blood cell. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change
. Thus. A reverse sequence of reactions occurs when blood reaches the lung. 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. where the partial pressure of carbon dioxide is lower than in the blood. 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.
Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. because of the increased size of inspired breaths. and almost all blood entering the lungs participates in gas exchange. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. In contrast to the cyclic nature of ventilation. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of
. Between these two events. Under ideal circumstances. because only free carbon dioxide easily crosses biologic membranes.7
The Respiratory System
or binding. yet this pool is important. In health.
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. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. not all inspired air participates in gas exchange. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. 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. 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. most carbon dioxide is transported as bicarbonate or carbamate. blood flow through the lung is continuous. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs.
Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs.
abnorMal gas exchange
Lung disease can lead to severe abnormalities in blood gas composition. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. shunting. ventilation– blood flow imbalance. A reduction in arterial blood oxygenation is seen with shunting. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. alveoli filled with fluid or inflammatory material).g. venous blood enters the bloodstream without passing through functioning lung tissue. but the level of carbon dioxide in arterial blood is not elevated even
Gas Exchange and Respiratory Adaptation
gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. and limitations of diffusion.. Because of the differences in oxygen and carbon dioxide transport. If the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange—a condition known as hypoventilation—the alveolar partial pressure of carbon dioxide rises and the partial pressure of oxygen falls almost reciprocally. In shunting. This abnormality leads to parallel changes in both gas and blood and is the only abnormality in gas exchange that does not cause an increase in the normally small difference between arterial and alveolar partial pressures of oxygen.
but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide. Blood leaving an unventilated area of the lung has
. The differing effects of shunting on oxygen and carbon dioxide partial pressures are the result of the different configurations of the blood-dissociation curves of the two gases. In contrast. Because the carbon dioxide–dissociation curve is steep and relatively linear. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. As noted earlier. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. and the composite arterial blood carbon dioxide content remains normal. As a result. compensation for decreased carbon dioxide exchange in one portion of the lung can be counterbalanced by increased excretion of carbon dioxide in another area of the lung. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung. which is usually achieved without difficulty. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure.7
The Respiratory System
though the shunted blood contains more carbon dioxide than arterial blood. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. When blood perfusing the collapsed. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal. the content of carbon dioxide is greater than the normal carbon dioxide content.
which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. In alveoli that are overventilated. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. a plateau is reached at the
Gas Exchange and Respiratory Adaptation
an oxygen content that is less than the normal content. 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. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. therefore. 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. Inspired air and blood flow normally are distributed uniformly. and an increase in blood partial pressure results in a negligible increase in oxygen content. in the arterial blood. reaches a plateau at the normal alveolar partial pressure. Thus. alveoli become either overventilated or underventilated in relation to their blood flow. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. and each alveolus receives approximately equal quantities of both. however. the amount of carbon dioxide eliminated is increased. Overventilated alveoli. however. 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. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. The oxygen-dissociation curve. In the healthy area of the lung.
which facilitates carbon dioxide exchange. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. A variety of processes can interfere with this orderly exchange. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. the greater the reduction in blood oxygenation. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. 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. Carbon dioxide exchange. and decreased time available for exchange due to increased velocity of flow. a reduction in the alveolar partial pressure of oxygen required for diffusion. For oxygen. 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. these include increased thickness of the alveolar–capillary membrane. These factors are usually grouped under the broad description of “diffusion limitation.7
The Respiratory System
alveolar partial pressure of oxygen. however. loss of surface area available for diffusion of oxygen. and increased ventilation will not increase blood oxygen content. In disease.
. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane.
the heart was regarded as a furnace where the “fire of life” kept the blood boiling. For gas exchange that takes place in the lungs. circulation. cells set the demand for oxygen uptake and carbon dioxide discharge. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). The proper functioning of the respiratory system depends on both the ability of the system to make functional adjustments to varying needs and the design features of the sequence of structures involved. the mitochondria. and MetabolisM
The interplay of respiration. ATP is degraded to adenosine diphosphate (ADP). This involves transport of oxygen from the lung to the tissues by means of the circulation of blood. In antiquity and the medieval period. The precise object of respiration therefore is the supply of oxygen to the mitochondria. whose third phosphate bond can release a quantum of energy to fuel many cell processes. In the process. The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. through the oxidation of foodstuffs such as glucose. such as the contraction of muscle fibre proteins or the synthesis of protein molecules. which set the limit for respiration. The circulation of the blood links the sites of oxygen use and uptake. and metabolism is the key to the functioning of the respiratory system as a whole. Each cell maintains a set of furnaces. the energetic needs of the cells are supplied.7
Gas Exchange and Respiratory Adaptation
interplay of respiration. where. circulation. Modern cell biology has unveiled the truth behind the metaphor. To recharge the molecule by adding the third phosphate group requires energy derived from
. a molecule with only two phosphate bonds.
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. anaerobic glycolysis. which operates in the absence of oxygen. the aerobic metabolic pathway is therefore preferable. or fermentation. Two pathways are available: 1. aerobic metabolism. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. transferred to blood in the lungs. will die. It begins with
. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. For any sustained highlevel cell activity. many cells. or its need for oxygen.7
The Respiratory System
the breakdown of foodstuffs. In contrast. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. and 2. because the cells maintain only a limited store of highenergy phosphates and of oxygen. or substrates. Because oxidative phosphorylation occurs only in mitochondria. If oxygen supply is interrupted for a few minutes. or even the organism. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. Oxygen is collected from environmental air. and since each cell must produce its own ATP (it cannot be imported). which requires oxygen and involves the mitochondria. aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. whereas they usually have a reasonable supply of substrates in stock. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system.
This is accompanied by an increased cardiac output. Blood also serves as carrier for both respiratory gases: oxygen. sets the demand for oxygen. more accurately the metabolic rate of the cells. and by
. As more and more muscle cells become engaged in doing work. 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. or. which is determined by its content of hemoglobin in the red blood cells. and carbon dioxide. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. the demand for ATP and oxygen increases linearly with work rate.7
Gas Exchange and Respiratory Adaptation
ventilation of the lung. a human consumes about 250 ml of oxygen each minute. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. which is achieved by convection or mass flow of air through an ingeniously branched system of airways. transport by blood flow. With exercise this rate can be increased more than 10-fold in a normal healthy individual. Metabolism. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. and discharge to the cells. At rest.5 micrometre) and the surface area of the barrier. essentially resulting from a higher heart rate. but a highly trained athlete may achieve a more than 20-fold increase. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. which is bound to hemoglobin in the red blood cells. In the most peripheral airways. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood.
because of the complexity of the system. this is called adaptive variation. based on observations that oxygen consumption rates differ significantly among species. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. well below interspecies differences. a feature called allometric variation. have an aerobic scope more than twofold greater than that of other animals of the same size. oxygen consumption per unit body mass increases as animals become smaller. but beyond the aerobic scope they must revert to anaerobic metabolism. 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. accumulate and limit the duration of work. the athletic species in nature. Much has been learned from comparative physiology and morphology. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. For example. but it is not straightforward. Muscle can do more work. such as dogs or horses. The limit to oxidative metabolism is therefore set by some features of the respiratory system. Consequently. from the lung to the mitochondria. mainly lactic acid. the aerobic scope can be increased by training in an individual. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. Then.
The Respiratory System
increased ventilation of the lungs. with the result that waste products. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. Furthermore. so that a mouse consumes six times as much oxygen per gram of body mass as a cow.
Within the aerobic scope the adjustments are caused by functional variation. cardiac output is augmented by increasing heart rate. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. If energy (ATP) needs to be produced at a higher rate. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system.
. in all types of variation. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. Mitochondria set the demand for oxygen. Shutterstock. In training. For example. the mitochondria increase in proportion to the augmented aerobic scope.7
Gas Exchange and Respiratory Adaptation
Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. the muscle cells make more mitochondria. This difference arises from a phenomenon known as adaptive variation.
such as in training. the lung lacks this capacity to adapt. rate. the blood. The issue of peripheral versus central limitation is still under debate. however. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. the blood vessels. which determines the volume of blood that can be pumped with each stroke. the levels of hemoglobin in the blood. or volume to augment their capacity when energy needs increase. the structure of the alveoli in the lungs. beyond which oxidative metabolism cannot be increased by training.
. But. In the case of adaptation to high altitudes. It appears. 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. at the last step of aerobic metabolism. In the cases of swimming and diving. If this proves true. both in terms of rate and of the size of the ventricles. and the heart can increase in number.7
The Respiratory System
It is thus possible that oxygen consumption is limited at the periphery.
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. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. whereas the mitochondria. whose capacity to pump blood reaches a limit. mainly the heart. the lung may well constitute the ultimate limit for the respiratory system. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected.
Gas Exchange and Respiratory Adaptation
Ascent from sea level to high altitude has well-known effects on respiration. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen. which heighten the partial pressure of oxygen at all stages. whether undertaken deliberately or not. Indigenous mountain species such as the
At high altitudes. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. Bishop/National Geographic/Getty Images
. such as cattle. Barry C. both in the ambient air and in the alveolar spaces of the lung. This very fall poses the major respiratory challenge to humans at high altitude. commences from the time of exposure to high altitudes. which. Humans and some other mammalian species.
which increases the amount of oxygen transported to the tissues. With a prolonged stay at altitude. thought to enhance oxygen perfusion of the lung apices. As the oxygen deprivation persists. 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 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. on the other hand. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. In addition. the tissues develop more blood vessels. Diffusion of oxygen across the alveolar walls into the blood is facilitated. the carotid bodies.3DPG. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. such as 2. as capillary density is increased. and. the size of muscle fibres decreases. which also shortens the diffusion path of oxygen. where oxygen is needed for the ultimate biochemical expression of respiration. the carotid bodies enlarge but become less sensitive to the lack of oxygen.7
The Respiratory System
llama. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. attached to the division of the carotid arteries on either side of the neck.
. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. which takes the form of deeper breathing rather than a faster rate at rest. exhibit an adaptation that is heritable and has a genetic basis. from the alveolar spaces in the lung to the mitochondria in the cells.
Gas Exchange and Respiratory Adaptation
Indigenous mountain animals like the llama. including humans. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the
. Human respiration requires ventilation with air.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. exhibit a set of responses that may be called a “diving reflex. or benign tumour. A chemodectoma. Other physiological changes are also observed. After living many years at high altitude. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. and their carotid bodies remain small. This disease is characterized by greater levels of hemoglobin. In contrast to acclimatized humans. and vicuña in the Andes or the yak in the Himalayas are adapted rather than acclimatized to the low oxygen partial pressures of high altitude. these indigenous. sometimes called Monge disease. They do not develop small muscular blood vessels or an increased blood pressure in the lung. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude.
Swimming and Diving
Fluid is not a natural medium for sustaining human life after the fetal stage. Their hemoglobin has a high oxygen affinity. Nevertheless. all vertebrates. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. after the Peruvian physician who first described it. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. alpaca. some highlanders lose this acclimatization and develop chronic mountain sickness.
may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. When the accumulated carbon dioxide at last forces the swimmer to return to the surface. however.7
The Respiratory System
same time that a diver is breathing from an independent gas supply. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. But this apparent advantage introduces additional hazards. the absolute pressure. Hyperventilation can be dangerous. At the depth of a diver. but the oxygen content of the blood concurrently falls to unusually low levels. and this danger is greatly increased if the swimmer descends to depth. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. Two factors are involved. Unconsciousness may then occur in or under the water. but it cannot provide an equivalent increase in oxygen. and consciousness remains unimpaired. 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. which is
. The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. Hyperventilation. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. Most hazards result from the environmental pressure of water. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath. many of them unique in human physiology. as sometimes happens in snorkeling.
the levels of inspired oxygen are
. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. 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. This may be compounded by an increased inspiratory content of carbon dioxide. Alveolar oxygen levels can also be disturbed in diving.7
Gas Exchange and Respiratory Adaptation
approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. 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 blood and tissues of the diver. is the vertical hydrostatic pressure gradient across the body. and the consequences of the uptake of respiratory gases into. Hypoxia may result from failure of the gas supply and may occur without warning. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. often with the formation of bubbles. More commonly. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). and their subsequent elimination from. rather than cardiac or muscular performance. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. is one factor. The other factor. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. The increased work of breathing. the increased density of the respiratory gases. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. is the limiting factor for hard physical work underwater. acting at any depth.
The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. In mixed-gas diving. which in a mixture with less than 4 percent oxygen is noncombustible. At the extreme depths now attainable by humans— some 500 metres (1. has the additional advantage of providing a breathing gas of lesser density. High values of end-tidal carbon dioxide with
.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. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. provides a greater respiratory advantage for deep diving.5 bar.5 bar (“surface equivalent value” = 150 percent). 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.7
The Respiratory System
increased. 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. it may cause the rapid onset of convulsions.2 and 0.640 feet) in the sea and more than 680 metres (2. The use of hydrogen. Oxygen in excess can be a poison. approximately in proportion to the reciprocal of the square root of the increasing gas density. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. like an anesthetic. At a partial pressure greater than 1.
or it may be effectively greater. This is a major cause of death among divers. has proved useful in designing underwater breathing apparatuses. places the diver at great risk. which represents the net effect of the external pressures and the effects of chest buoyancy. the expanding gas may rupture alveolar septa and escape into interstitial spaces. resulting in less intrathoracic blood volume. More seriously. if it occurs underwater. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. a condition that.7
Gas Exchange and Respiratory Adaptation
only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. possibly extending into the pericardium or into the neck. in which case more blood will be shifted into the thorax. And whatever the orientation of the diver in the water. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. The concept of a hydrostatic balance point within the chest. Unless vented. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. Failure to exhale
. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). Also.
even from depths as shallow as 2 metres (6.6 feet). can result in a sometimes life-threatening condition known as decompression sickness. Inadequacy of diver decompression.
. 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. 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.7
The Respiratory System
during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.
and may be highly contagious. various types of pneumonia. whether of the upper or lower respiratory tract. as considered here. can be effectively treated with prescription antimicrobial drugs. requiring patient hospitalization. with this division occurring at the anatomical level of the larynx. Thus. and tuberculosis. and molds. Examples of severe lower respiratory infections include croup. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. In most cases. Legionnaire disease. These diseases may be caused by a variety of agents. Some conditions can cause extensive lung damage. and tonsillitis. pharyngitis. however. tracheitis. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues.CHAPTER4
INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM
nfectious diseases are among the most common conditions affecting the human respiratory system. upper respiratory infections include the common cold. sinusitis. infectious diseases.
. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. bacteria. However. including viruses. whereas lower respiratory infections include laryngitis. and any condition of the bronchi and lungs. resulting in patient isolation.
an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. and the
. however. Rhinoviruses. pharynx. In other cases. Some of these infections may resolve on their own. Incubation is short. or drafts. respiratory syncytial viruses. usually one to four days.7
The Respiratory System
upper respiratory systeM infections
The nasal sinuses. More than 200 agents can cause symptoms of the common cold. The feeling was originally believed to have a cause-and-effect relationship with the disease. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. and may cause secondary infections in the eyes or middle ears. influenza. The cold is caught from exposure to infected people. sometimes spreads to the lower respiratory structures. People can carry the virus and communicate it without experiencing any of the symptoms themselves. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. chilled wet feet. are the most frequent cause. however. with little or no medication.
The common cold is an acute viral infection that starts in the upper respiratory tract. and tonsils are frequently the site of both acute and chronic infections. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. and reoviruses. The viruses start spreading from an infected person before the symptoms appear. including parainfluenza. not from a cold environment. but this is now known to be incorrect.
Once a virus becomes established on the respiratory surface of the nose. which respond by pouring out streams of clear fluid. Symptoms abate as the host’s defenses increase. a second method of expelling the virus. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. and nasal discharge. but in the individual the same symptoms tend to recur in succeeding bouts of infection. Cold symptoms vary from person to person. It may result from the greater amount of time spent indoors. This fluid acts to dilute the virus and clear it from the nose. If the virus penetrates more deeply into the upper respiratory tract.7 Infectious Diseases of the Respiratory System
spread reaches its peak during the symptomatic phase. There is no effective antiviral agent available for the common
. usually coming into contact with the infectious agents in day care centres or preschools. thereby setting up sneezing. The incidence of colds peaks during the autumn. The usual duration of the illness is about five to seven days. but the reason for this incidence is unknown. the clear fluid often changing to a thick. which increases the likelihood of close contact with those persons carrying cold viruses. There is usually no fever. and minor epidemics commonly occur throughout the winter. The nasal discharge is the first warning that one has caught a cold. but it is possible to take a culture for viruses. Symptoms may include sneezing. Young children can contract between three and eight colds a year. Coughing can be dry or produce amounts of mucus. sore throat. fatigue. its activities irritate the nose’s cells. but lingering cough and postnasal discharge may persist for two weeks or more. The sensory organs in the nose are stung by the inflammatory reaction. Diagnosis of a cold is usually made by medical history alone. yellow-green fluid that is full of the debris of dead cells. inflammation of the nose (rhinitis). headaches. chills.
The Respiratory System
Usually. sore throat. Shutterstock. chills. fatigue. but it can comprise sneezing. and nasal discharge. rhinitis. the common cold does not involve a fever. headaches.com 90
or a reaction to certain drugs. as are antiseptic gargles. fungi. and tonsils. and nasal congestion. Infection by
. the throat reddens. 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 the tonsils may secrete pus and become swollen. a result of irritation by foreign objects or fumes.
Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. mycoplasmas. A sore throat may be a symptom of influenza or of other respiratory infections. For a viral sore throat. Generally. which typically subside after one week. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. 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. In treating nonviral sore throat. The illness can be caused by bacteria. viruses. antibiotics are often effective.7 Infectious Diseases of the Respiratory System
cold. In many studies.
Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). treatment is aimed at relieving symptoms. administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. soft palate. Therapy consists of treating the symptoms: relieving aches. Inflammation usually involves the nasopharynx. uvula. and parasites and by recognized diseases of uncertain causes. fever.
Chronic cases caused by irritants in the environment or by
. swelling of lymph nodes. including tuberculosis. Viral pharyngitis infections also occur.
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 meningitis. appropriate antibiotic therapy. and irritability. a pustulant fluid on the tonsils or discharged from the mouth. They cause fever. usually with penicillin. however. and the cause of pharyngeal inflammation can be determined by throat culture. headache. nausea. If a diagnosis of streptococcal infection is established by culture. Lymphatic tissue in the pharynx may also become involved. and a slight fever. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. but the other symptoms may persist for another two to three days. headache. A number of other infectious diseases may cause pharyngitis. Diagnosis is established by a detailed medical history and by physical examination. syphilis. Purulent (pus-producing) sinusitis can occur. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. Within approximately three days the fever leaves. diphtheria. extremely sore throat that is felt during swallowing. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. and sore throat that last for 4 to 14 days. requiring treatment with antibiotics.7
The Respiratory System
Streptococcus bacteria may be a complication arising from a common cold. is instituted. sometimes in children there are abdominal pain.
Under normal conditions.7 Infectious Diseases of the Respiratory System
impaired immune systems may require more extended treatment. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. infection can be established. Following a common cold. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. The organisms usually involved are Haemophilus influenzae. The origin of acute sinus infection is much like that of ear infection. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. Streptococcus pyogenes. When ciliary function is damaged. but the adjacent mouth and nose have a varied bacterial flora. including surgery. and many other penicillin-sensitive anaerobes. keeping the sinuses clean. nasal discharge. Common symptoms include facial pain. On physical examination. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. If the infection persists. Normally the middle ear and the sinuses are sterile. Treatment of acute sinusitis is directed primarily at overcoming the infecting organism by the use of systemic antibiotics such as penicillin and at encouraging drainage of the sinuses by the use of vasoconstricting nose drops and inhalations. and sinus tenderness. and fever following previous upper respiratory viral illness. It may also be caused by allergy to agents
. 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. headache. Chronic sinusitis may follow repeated or neglected attacks of acute sinusitis. Streptococcus pneumoniae. Staphylococcus aureus.
The Respiratory System
in the environment. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. repeated or persistent sore throat. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. Pain is not a feature of chronic sinusitis. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. malaise. The symptoms of chronic sinusitis are a tendency to colds. In severe cases endoscopic surgery may be necessary to remove obstructions. difficulty in swallowing. with or without heart involvement. The infection may extend upward into the nose. and ears or downward into the larynx. usually hemolytic streptococci or viruses. If antibiotic therapy or repeated lavage do not alleviate the condition. purulent nasal discharge. evidenced by tonsillar enlargement. loss of smell. and bronchi. such as fungi or pollen. trachea. obstructed breathing. fever. The
. and warm throat irrigations or gargles with a mild antiseptic solution. The infection lasts about five days. virulent bacteria may spread from the infected tonsil to the adjoining tissues. Repeated acute infections may cause chronic inflammation of the tonsils. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. Locally.
Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. The treatment includes bed rest until the fever has subsided. and enlarged lymph nodes on both sides of the neck. sinuses. isolation to protect others from the infection. and sometimes headache. and swollen lymph nodes in the neck. The symptoms are sore throat. resulting in a peritonsillar abscess.
involving long-term antimicrobial therapy. Likewise. Usually the mucous membrane lining the larynx is the site of prime infection. adherent membrane. pneumonia. and contains many
. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. Scarlet fever.
Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. Nonbacterial agents such as chlorine gas. For example. Laryngitis is classified as simple. In diphtheria the tonsils are covered with a thick. with a grayish membrane that wipes off readily. tuberculous. the infectious disease tuberculosis. which is a major cause of lung disease globally. or syphilitic. secretes a thick mucous substance. steam.
lower respiratory systeM infections
Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. whitish.7 Infectious Diseases of the Respiratory System
treatment in this case is surgical removal (tonsillectomy). Simple laryngitis is usually associated with the common cold or similar infections. is associated with a high rate of death in infants and the elderly. in trench mouth. and trench mouth may also produce acute tonsillitis. diphtheritic. Thus. It becomes swollen and filled with blood. or sulfur dioxide can also cause severe inflammation. diphtheria. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. in order to prevent potentially disabling damage to lung tissue. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction.
small lumps of tissue that project from the surface. sores or mucous patches can form. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. The mucous membrane becomes dry and covered with polyps. Most conditions that affect the trachea are bacterial or
. and diseased skin cells to attach to and infiltrate the surface mucous membrane. and produce a permanent hoarseness of the voice. the larynx can become obstructed. alcoholism. As the disease advances to the third stage. When the epiglottis. The bacteria die after infecting the tissue. fibrin (blood clotting protein). becomes swollen and infected by influenza viruses. In the second stage of syphilis. A similar type of membrane covering can occur in streptococcal infections. Syphilitic laryngitis is one of the many complications of syphilis. The scars can distort the larynx. Chronic laryngitis is produced by excessive smoking. The wall of the larynx may thicken and become inflamed. tissue destruction is followed by healing and scar formation. shorten the vocal cords.
Tracheitis is an inflammation and infection of the trachea. leaving ulcers on the surface.7
The Respiratory System
inflammatory cells. or overuse of the vocal cords. Tubercular nodule-like growths are formed in the larynx tissue. It may cause a membrane of white blood cells. they may consolidate at the vocal cords and cause an obstruction there. and suffocation may result. There may be eventual destruction of the epiglottis and laryngeal cartilage. When looser portions of this false membrane become dislodged from part of the larynx. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. which closes the larynx during swallowing.
although irritants like chlorine gas. such as those that occur on the external skin. and small polyplike formations occasionally grow. Blood vessels increase in number. Generally. but the trachea may also be attacked. The walls of the trachea during chronic infection contain an excess of white blood cells.7 Infectious Diseases of the Respiratory System
viral infections. Typhoid causes swelling and ulceration in the lymph tissue. The mucous glands may become swollen. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. and syphilis all afflict the trachea. form in the mucous membrane. they do not cause significant damage to the tissue unless they become chronic. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. Irritants such as heavy smoking and alcoholism may invite infections. fatigue. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. Common bacterial causes of acute infections are pneumococci. and the walls thicken because of an increase in elastic and muscle fibres. pustules and ulcers. The infections produce fever. Degenerated tissue is eventually replaced by a fibrous scar tissue. In smallpox. hemorrhages. Diphtheria usually involves the upper mouth and throat. sulfur dioxide. Neisseria organisms. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. tuberculosis. and staphylococci. streptococci. and swelling of the mucous membrane lining the trachea. Intense blood congestion. Chronic infections recur over a number of years and cause progressive degeneration of tissue. smallpox. and degeneration of the tracheal tissue can occur. Acute infections occur suddenly and usually subside quickly. Diphtheria. Infections may last for a week or two and then pass. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. Syphilis forms lesions that erode the
making it necessary for the patient to sit and lean
. spasms of the laryngeal muscles. with high fever and breathing difficulties. Generally. and can cause thickening and stiffening of the spaces between the cartilage. and difficult breathing. It is most often caused by an infection of the airway in the region of the larynx and trachea.7
The Respiratory System
tissue. The symptoms are caused by inflammation of the laryngeal membranes. Because of the marked swelling of the epiglottis. the onset of viral croup is preceded by the symptoms of the common cold for several days. or inflammation around the trachea. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. there is obstruction at the opening of the trachea. also called epiglottitis. the most frequent being those with the parainfluenza and influenza viruses. In some cases. It is characterized by marked swelling of the epiglottis. The onset is usually abrupt. inflammation occurs around the bronchial tree.
Croup is an acute respiratory illness of young children that is characterized by a harsh cough. Bacterial croup. Viral infections are the most common cause of croup. hoarseness. and they strike most frequently in late fall and winter. Such infections are most prevalent among children younger than age three. Epinephrine and corticosteroids have also been used to reduce swelling of the airway. is a more serious condition that is often caused by Haemophilus influenzae type B. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. Some cases result from allergy or physical irritation of these tissues. In cases of severe airway obstruction. hospitalization may be necessary.
An artificial airway must be opened. influenzae. however. or organic solvents. The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. Therefore. preferably by inserting a tube down the windpipe. it is often part of the common cold and is a common sequel to influenza.7 Infectious Diseases of the Respiratory System
forward to maximize the airflow. organisms do enter the airways and initiate a sudden and rapid attack. Under ordinary circumstances. and measles. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. particularly in people who have underlying chronic lung disease. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. Under certain circumstances. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. 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. whooping cough. It is most frequently caused by viruses responsible for upper respiratory infections. ammonia.
Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi).
. which generally relieve the inflammation within 24 to 72 hours. resulting usually in a relatively brief disease called acute infectious bronchitis. Acute bronchitis can also be caused by bacteria such as Streptococcus. In addition. Epiglottitis generally strikes children between ages three and seven. through which air passes into the lungs. Children with epiglottitis require prompt medical attention. Patients are given antibiotics.
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. discussed in a later chapter.
Bronchiolitis refers to inflammation of the small airways. In isolated cases. and expectorants will usually relieve the symptoms. but it normally clears spontaneously. and particularly in infections with respiratory syncytial virus.
. is a long-standing. with complete healing in all but a very small percentage of cases. an acute bronchiolitis episode is followed by a chronic obliterative condition. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal. In adults. though there is little doubt that in most patients with chronic bronchitis.7
The Respiratory System
Treatment of acute bronchitis is largely symptomatic and of limited benefit. bronchodilators. Another form of bronchitis. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. particularly in children between ages one and two. Steam inhalation. called chronic bronchitis. Bronchiolitis probably occurs to some extent in acute viral disorders. In addition to patients acutely exposed to gases. in whom such a syndrome may follow the acute exposure. In some cases the inflammation may be severe enough to threaten life. This pattern of occurrence has only recently been recognized. or this may develop slowly over time. which results in protracted and often permanent damage to the bronchial mucosa.
or in fires involving plastic materials.
. and the lesion is an acute bronchiolitis. is characteristically not followed by acute symptoms. These develop some hours later. Monty Rakusen/Cultura/Getty Images
Exposure to oxides of nitrogen. An inflammation around the small airways. after blasting underground. A chest radiograph shows patchy inflammatory change. which may occur from inhaling gas in silos. 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. is believed to be the earliest change that occurs in the lung in cigarette smokers. known as a respiratory bronchiolitis.7 Infectious Diseases of the Respiratory System
Welding in enclosed spaces often results in exposure to oxides of nitrogen. but a short cough and progressive shortness of breath may not be evident for hours.
bronchial tubes. and muscle aches. is an acute viral infection of the upper or lower respiratory tract that is marked by fever.
Influenza. In three to four days the temperature begins to fall. and trachea. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. and a generalized feeling of weakness and pain in the muscles. together with varying degrees of soreness in the head and abdomen. The flu may affect individuals of all ages. Symptoms associated with respiratory tract
. though the highest incidence of the disease is among children and young adults. As the virus particles gain entrance to the body. also known simply as the flu (or grippe). The temperature rises rapidly to 38–40 °C (101–104 °F). Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. by such means as inhalation of infected droplets resulting from coughing and sneezing. A diffuse headache and severe muscular aches throughout the body are experienced. and the person begins to recover. and it is generally more frequent during the colder months of the year. often accompanied by irritation or a sense of rawness in the throat. fatigue. It is not known whether those who develop this change (after possibly only a few years of smoking) are or are not at special risk of developing the long-term changes of chronic bronchitis and emphysema. chills.7
The Respiratory System
although it does not lead to symptoms of disease at that stage. The inflammation is probably reversible if smoking is discontinued. after which the onset of symptoms is abrupt. The incubation period of the disease is one to two days. with sudden and distinct chills.
Other than this. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. and the use of analgesics to control fever. as well as a strain of virus known as influenza type B. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. 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. a very serious illness.7 Infectious Diseases of the Respiratory System
infection. routine immunization in healthy people is also recommended. ingestion of fluids. Protection from one vaccination seldom lasts more than a year. These viruses are produced in chick embryos and rendered noninfective. Death may occur. the neuraminidase inhibitors. In order to prevent humaninfecting bird flu viruses from mutating into more
. viral resistance to these agents has been observed. usually among older people already weakened by other debilitating disorders. these drugs inhibit influenza A. and is caused in most of those cases by complications such as pneumonia or bronchitis. However. such as coughing and nasal discharge. as treatment of viral infections with aspirin is associated with Reye syndrome. However. become more prominent and may be accompanied by lingering feelings of weakness. was introduced in the late 1990s. thereby reducing their effectiveness. A newer category of drugs. the standard treatment remains bed rest.
has developed resistance to oseltamivir. known as H1N1. Through the inhibition of neuraminidase. Inc. increases the formation of viral aggregates. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. increases the formation of viral aggregates. Oseltamivir is effective when administered within two days of symptom onset. Oseltamivir can be given orally. a glycoprotein on the surface of influenza viruses. The drug can also be used to prevent flu in adults and children who take the medication once daily for a period of at least 10 days.7
The Respiratory System
dangerous subtypes. 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 and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. Zanamivir is given by inhalation only. the drug decreases the release of virus from infected cells. If taken within 30 hours of
. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline.S. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. and decreases the spread of the virus through the body.based pharmaceutical company Hoffman–La Roche. Oseltamivir (Tamiflu) Oseltamivir 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. zanamivir decreases the release of virus from infected cells. There is evidence that the most common subtype of influenza type A virus.S.
Bordetella pertussis. Centers for Disease Control and Prevention (CDC) (Image Number: 2121)
. the causative agent of whooping cough. Zanamivir.
Whooping cough. isolated and coloured with Gram stain. highly communicable respiratory disease.7 Infectious Diseases of the Respiratory System
the onset of influenza.” The coughing ends with the expulsion of clear. when taken once daily for 10 to 28 days. zanamivir can shorten the duration of the illness. sticky mucus and often with vomiting. is an acute. or “whoop. Whooping cough is caused by the bacterium Bordatella pertussis. can prevent influenza infection in some adults and children. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. or pertussis.
After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. and a low-grade fever. Beginning its onset after an incubation period of approximately one week. Whooping cough is worldwide in distribution and among the most acute infections of children. Immunization is routinely begun at two months of age and requires five shots for maximum
. there is a repetitive series of coughs that are exhausting and often result in vomiting. Now included in the DPT (diphtheria. In 1906 at the Pasteur Institute. slowed or stopped breathing. the name pertussis (Latin: “intensive cough”) was introduced in England. ear infections. It was first called the Bordet-Gengou bacillus. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. variable in duration but commonly lasting four to six weeks. About 100 years later. the illness progresses through three stages—catarrhal. and convalescent—which together last six to eight weeks. During the convalescent stage there is gradual recovery. later Haemophilus pertussis. but the periods between coughing paroxysms are comfortable. and pertussis) vaccine. undoubtedly it had existed for a long time before that. The infected person may appear blue. and occasionally convulsions and indications of brain damage. with bulging eyes. red eyes. paroxysmal. and be dazed and apathetic. it confers active immunity against whooping cough to children. In the paroxysmal state. with a short dry cough that is worse at night. The disease was first adequately described in 1578.7
The Respiratory System
Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. and still later Bordetella pertussis. tetanus. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. Catarrhal symptoms are those of a cold. Complications of whooping cough include pneumonia.
Psittacosis. from which the disease is named). although a thorough study of the disease was not made until 1929– 30. Treatment includes erythromycin. During the investigations conducted in Germany. ducks. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. an antibiotic that may help to shorten the duration of illness and the period of communicability. The infection has been found in about 70 different species of birds. also known as ornithosis (or parrot fever). pigeons. and sometimes the use of an oxygen tent is required to ease breathing. parrots and parakeets (family Psittacidae. Strict regulations followed concerning
. Later vaccinations are in any case thought to be unnecessary. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. the causative agent was revealed. and another booster is given when the child is between four and six years old. especially if they have been vaccinated in infancy. when severe outbreaks. A booster dose of pertussis vaccine should be given between 15 and 18 months of age. occurred in 12 countries of Europe and America. turkeys. and the United States. and geese are the principal sources of human infection. England. Sedatives may be administered to induce rest and sleep. because the disease is much less severe when it occurs in older children. attributed to contact with imported parrots.7 Infectious Diseases of the Respiratory System
protection. The association between the human disease and sick parrots was first recognized in Europe in 1879.
ducks. Psittacosis usually causes only mild symptoms of illness in birds. thus inviting secondary pneumonia caused by bacteria. but the most common causes are bacteria. and convalescence often is protracted. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. or irradiation. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. Before modern antibiotic drugs were available. have reduced resistance to
. inhalation of foreign particles. but penicillin and the tetracycline drugs reduced this figure almost to zero.7
The Respiratory System
importation of psittacine birds. in particular species of Streptococcus and Mycoplasma. but in humans it can be fatal if untreated. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. Fungal pneumonia can develop very rapidly and may be fatal. In humans psittacosis may cause high fever and pneumonia. The typical duration of the disease is two to three weeks. and an elevated respiratory rate. Many organisms. viruses more commonly play a part in weakening the lung. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. or geese have caused many cases among poultry handlers or workers in processing plants. Other symptoms include chills. Infected turkeys. head and body aches. including viruses and fungi. because of impaired immunity. can cause pneumonia.
Pneumonia is an inflammation and solidification of the lung tissue as a result of infection. Although viral pneumonia does occur. weakness. the case fatality rate was approximately 20 percent. but it usually occurs in hospitalized persons who.
when inhaled by previously healthy individuals. These fluids provide an environment in which the bacteria flourish. smoke inhalation). however. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the
. or allergic response. and recovery generally occurs in a few weeks. In some cases. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. Bacterial Pneumonia Streptococcal pneumonia. chest pain. particularly in elderly people and young children. 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 animal excreta or to chemical or physical injury (e. cough. and difficulty in breathing. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. As the disease progresses. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract. coughing becomes the major symptom. Treatment is with specific antibiotics and supportive care. Pneumonia can also occur as a hypersensitivity. the illness may become very severe. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing.. especially in hospitalized patients.g. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. Sputum discharge may contain flecks of blood. and it is sometimes fatal.7 Infectious Diseases of the Respiratory System
infection. humidifiers. caused by Streptococcus pneumoniae. can sometimes cause fungal lung diseases. Contaminated dusts. to agents such as mold. is the single most common form of pneumonia.
The Respiratory System
lungs. it does not invade the deeper tissues—muscle fibres. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. M. Symptoms of
. although epidemics can occur. Usually the organism does not invade the membrane that surrounds the lungs. Klebsiella pneumoniae. causing bleeding into the air spaces. Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. elastic fibres. but it does sometimes inflame the bronchi and alveoli. Mycoplasmal pneumonia. few cases beyond age 50 are seen. which leads to the further release of pneumolysin. caused by Legionella pneumophilia. and psittacosis. parainfluenza. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. an extremely small organism. caused by Mycoplasma pneumoniae. Other bacterial pneumonias include Legionnaire disease. small neighbourhoods. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. an atypical infectious form. or nerves. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. usually affects children and young adults. although it has little ability to infect the lungs of healthy persons. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. 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. Another bacterium. Most outbreaks of this disease are confined to families. and influenza viruses.
or other chronic diseases. people exposed to rats. and doves may develop manifestations of hypersensitivity pneumonia. In addition. shortness of breath. these patients experience fever with chills. maple logs. or dust storms. particularly if the patient was recently exposed to excavations. the prognosis is excellent. and air-conditioning ducts. all of which contain the fungus Actinomyces. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. A more insidious form of hypersensitivity pneumonia is
. backyard swimming pools. These pneumonias may occur following exposure to moldy hay or sugarcane. all of which may subside in a day if there is no further exposure. old sheds or barns. Nonbacterial pneumonia is treated primarily with supportive care. AIDS. Initially. gerbils. and skin testing is included in the initial examination of patients with lung problems. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. and low-grade fever. Tuberculosis should always be considered a possibility in any patient with pneumonia. cough. In general. headache. decreased appetite. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. usually followed by respiratory congestion and cough. and malaise. Diagnosis is established by physical examination and chest X-rays. room humidifiers. parakeets.7 Infectious Diseases of the Respiratory System
these pneumonias include runny nose. Other fungi found in barley. pigeons. and wood pulp may cause similar illnesses. muscle pain. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer.
The Respiratory System
associated with persistent malaise. Scar tissue forms as a result of the presence of the oil. Oil that is being swallowed may be breathed into the respiratory tract. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. This type of disease. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. and supportive care. it had been known that if the immune system was compromised by immunosuppressive drugs (given. Diagnosis is established by medical history. and specific laboratory tests. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. weight loss. Pneumonia in Immunocompromised Persons For some years prior to 1980. for example. Ordinarily no treatment is necessary. before organ transplantation to reduce the rate of rejection). or. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. Infections with fungi such as
. are difficult to treat. capable of causing invasive pneumonic lesions in the setting of reduced immunity.) Recovery is usual unless too great an area of lung tissue is involved. known as lipoid pneumonia. and cough. and may prove fatal. less often. physical examination. Such infections are a major cause of illness in these patients. fever. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. Treatment consists of removing the patient from the offending environment. it may come from the body itself when the lung is physically injured.
Coughing. shortness of breath. a U.7 Infectious Diseases of the Respiratory System
Candida also occur. as is water at construction sites. but not uniformly. at a Philadelphia hotel where 182 Legionnaires contracted the disease. confirmed in more than 300 people. and occasionally some mental confusion is present. 29 of them fatally. the first symptoms of Legionnaire disease are general malaise and headache. Although it is fairly well documented that the disease is rarely spread through person-to-person contact.
. Although healthy individuals can contract Legionnaire disease. followed by high fever. pneumophila in droplets into the surrounding atmosphere. occurred in Murcia. Spain. The largest known outbreak of Legionnaire disease. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. Typically. and abdominal distress are common.
Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. the exact source of outbreaks is often difficult to determine. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. pleurisy-like pain. Potable water and drainage systems are suspect. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. in 2001. often accompanied by chills.S. 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. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. military veterans’ organization.
an influenza-like illness characterized by fever. represents a milder form of Legionella infection. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. “consumption. headache. and death.7
The Respiratory System
Once in the body. the bacillus spreads slowly and widely in the lungs. Since the
. Blood vessels also can be eroded by the advancing disease. In most forms of the disease. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. and muscle pain. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. Mycobacterium tuberculosis. pneumophila. In some cases. this cycle of infection can lead to severe pneumonia. Eventually. However. Pontiac fever. coma. pneumophila enters the lungs. Treatment for Legionnaire disease is with antibiotics. at which time improved health and hygiene brought about a steady decline in its mortality rates. L. Indeed. 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.” as it was then known. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. L.
Tuberculosis is an infectious disease that is caused by the tubercle bacillus. During the 18th and 19th centuries. the macrophage dies and bursts open. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis.
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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. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. it continues to be a fatal disease continually complicated by drug-resistant strains. tuberculosis remains a major fatal disease. In addition. the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the
. Today. in less-developed countries where population is dense and hygienic standards poor. antibiotic drugs have reduced the span of treatment to months instead of years. but in areas with poor hygiene standards.7 Infectious Diseases of the Respiratory System
Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries.
and finally are sealed up in hard. Individual tubercles are microscopic in size. Infections with these strains are often difficult to treat and require the use of combination drug therapies. The Course of Tuberculosis The tubercle bacillus is a small. are surrounded by immune cells. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. but most of the visible manifestations of tuberculosis. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. In otherwise healthy children and adults. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. coughing. nodular tubercles. A tubercle usually consists of a centre of dead cells and tissues. from barely visible nodules to large tuberculous masses. sometimes called latent
. rod-shaped bacterium that is extremely hardy. the primary infection often heals without causing symptoms.7
The Respiratory System
rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. and a small scar in the lung may be visible by X-ray. sometimes involving the use of five different agents. it can survive for months in a state of dryness and can also resist the action of mild disinfectants. In this condition. Minute droplets ejected by sneezing. and the infected person acquires a lifelong immunity to the disease. There the bacilli become trapped in the tissues of the body. cheeselike (caseous) in appearance. in which can be found many bacilli. The bacilli are quickly sequestered in the tissues. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. are conglomerations of tubercles. A skin test taken at any later time may reveal the earlier infection and the immunity.
for example). an alarming symptom. and immunocompromised adults (organ transplant recipients or AIDS patients. however. In some cases. Fever develops. before the advent of specific drugs. the affected person is not contagious. causing miliary tuberculosis. though most affected people now recover. In fact. releasing viable bacilli into the bloodstream. the elderly. the primary infection may spread through the body. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. weight loss. An infection of the meninges that cover the brain causes tuberculous meningitis. Tubercular lesions
. a highly infectious stage of the disease. From the blood the bacilli create new tissue infections elsewhere in the body. with lack of energy. In some cases the infection may break into the pleural space between the lung and the chest wall. Eventually. most commonly in the upper portion of one or both lungs. they can travel to almost any organ of the body. kidneys. usually with drenching night sweats. or collection of fluid outside the lung. the patient may have chest pain from pleurisy. this disease was always fatal. skin. genital organs. the original tubercles break down. including the lymph nodes. This lesion may erode a neighbouring bronchus or blood vessel. the cough increases. and there may be blood in the sputum. causing the patient to cough up blood (hemoptysis). In the lung. The onset of pulmonary tuberculosis is usually insidious. causing a pleural effusion. and persistent cough. Particularly among infants. and the general health of the patient deteriorates. These symptoms do not subside. This causes a condition known as pulmonary tuberculosis. and bladder. once the bacilli enter the bloodstream. a highly fatal form if not adequately treated. sometimes after periods of time that can reach 40 years or more. intestines.7 Infectious Diseases of the Respiratory System
tuberculosis. bones and joints.
is characterized by softening and collapse of the vertebrae. where it causes destruction of tissue and eventually gross deformity. and this. M. cavities. has led to the disappearance of bovine tuberculosis in humans in many countries. M. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. and mycobacteria other than tuberculosis (MOTT). or Pott disease. M. atypical mycobacteria.
. and it is also excreted in milk. where it causes caseation of the node tissue (a condition formerly known as scrofula). Other Mycobacterial Infections Another species of bacteria. ulcerans. From the gastrointestinal tract. a great preference for bones and joints. Tuberculosis of the spine. bovis may spread into the bloodstream and reach any part of the body. If the milk is ingested raw. along with the systematic identification and destruction of infected cattle.7
The Respiratory System
may spread extensively in the lung. bovis is transmitted among cattle and some wild animals through the respiratory route. causing large areas of destruction. kansasii. M. marinum. The amount of lung tissue available for the exchange of gases in respiration decreases. finally eroding through the skin as a chronic discharging ulcer. bovis readily infects humans. This group includes such Mycobacterium species as M. The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. It shows. often resulting in a hunchback deformity. however. avium (or M. M. The node swells under the skin of the neck. M. and scarring. Pasteurization of milk kills tubercle bacilli. and M. bovis. aviumintracellulare). is the cause of bovine tuberculosis.
and this means treating infectious patients quickly. its use in young children in particular has helped to control infection in the developing world. or in the cerebrospinal fluid. Injected into the skin. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. is composed of specially weakened tubercle bacilli. stained with a compound that penetrates the organism’s cell wall. It has been widely used in some countries with success. in the urine. tuberculosis for several years. tuberculosis. known as BCG vaccine. it causes a local reaction. lymph nodes. Treatment is attempted with various drugs. the sputum specimen is cultured on a special medium to determine whether the bacilli are M.7 Infectious Diseases of the Respiratory System
These bacilli have long been known to infect animals and humans. individuals at risk
. The primary method used to confirm the presence of bacilli is a sputum smear. and examined under a microscope. An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. and other organs only in people whose immune systems have been weakened. in gastric washings. but they cause dangerous illnesses of the lungs. The main hope of ultimate control. Among AIDS patients. In many developed countries. which confers some immunity to infection by M. possibly in isolation until they are noninfectious. but the prognosis is usually poor owing to the AIDS patient’s overall condition. atypical mycobacterial illnesses are common complications of HIV infection. in which a sputum specimen is smeared onto a slide. lies in preventing exposure to infection. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. however. A vaccine. If bacilli are present.
often years. surgery is rarely needed.7
The Respiratory System
for tuberculosis. the surviving bacilli will become resistant to several drugs. As a result. ethambutol. 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. These drugs are often used in various combinations with other agents. treatment of tuberculosis consisted of long periods. 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. Historically. but complete cure requires continuous treatment for another four to nine months. These drugs may be given daily or two times per week. in order to avoid the development of drug-resistant bacilli. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. and pyrazinamide.
. The patient is usually made noninfectious quite quickly. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. If subsequent treatment is also incomplete. rifampicin. Today. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. pyrazinamide. making the patient sick again. or rifapentine. bacilli will become resistant and multiply. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). of bed rest and surgical removal of useless lung tissue. with early drug treatment. such as ethambutol. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. such as health care workers.
7 Infectious Diseases of the Respiratory System
Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin.
. it has proved successful in controlling tuberculosis. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. MDR TB is treatable but is extremely difficult to cure. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). 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. such as kanamycin. in part to prevent the development and spread of MDR TB. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. Aggressive treatment using five different drugs. or capreomycin. Although some patients consider DOT invasive. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. Instead of taking daily medication on their own. amikacin. In addition. In 1995. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week.
Conditions affecting these tissues may
. there are diseases of the upper airways. trachea. they are by no means rigid. ranging from inherited genetic mutations to smoking to trauma. 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. bronchial tree. Treatment for this group of conditions is similarly varied. and in many cases therapy may include not only the administration of medications but invasive surgery as well.CHAPTER5
DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM
here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. Although these divisions provide a general outline of the ways in which diseases may affect the lung. sinuses.
diseases of the upper airway
The nose. and disease in one region frequently leads to involvement of other parts. diseases of the larynx. Important examples of diseases and disorders of the respiratory system include sleep apnea. Thus. and lungs. palate. and diseases of the mediastinum and diaphragm. It is common for more than one part of the system to be involved in any particular disease process. emphysema. and cystic fibrosis. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect. and nasopharynx are all susceptible to disease.
Such cancers are typically more common in smokers than in nonsmokers. which necessitates breathing through the mouth..com / Stephanie Horrocks 123
. a potentially life-threatening condition. hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords. It is often associated with obstruction of the nasal passages.e. © www .7
Diseases and Disorders of the Respiratory System
result from a number of different causes. loud interrupted snoring can indicate sleep apnea. Snoring is more common in the elderly because the loss of tone in the oropharyngeal
Although snoring bears the brunt of many jokes.istockphoto. cancer). such as congenital structural abnormalities or malignant neoplastic changes (i.
Snoring is a rough.
or body-mass index. Thus. and mixed. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. a common and potentially lifethreatening condition that generally requires treatment. central. which involves characteristics of both obstructive and central apneas. at which point the airway reopens and the person resumes breathing. and it occurs most often in obese persons. body weight. the condition has a strong association with certain measures of obesity. In addition.” There are three types of sleep apnea: obstructive. which is the most common form and involves the collapse of tissues of the upper airway. meaning “without breath.
Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. In obstructive sleep apnea (OSA). Whatever the cause. In men shirt size is a useful predictor.7
The Respiratory System
musculature promotes vibration of the soft palate and pharynx. Loud interrupted snoring is a regular feature of sleep apnea. The word apnea is derived from the Greek apnoia. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. such as neck size. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. 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. Children’s snoring usually results from enlarged tonsils or adenoids. airway collapse is eventually terminated by a brief awakening. with the likelihood of OSA increasing
. Obstructive sleep apnea is most often caused by excessive fat in the neck area. It is also more common in men than in women.
and insulin resistance. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. The risk returns to normal after treatment. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. Treatment typically involves continuous positive airway pressure (CPAP). including ischemic heart disease.7 Diseases and Disorders of the Respiratory System
with a collar greater than about 42 cm (16. it does prevent airway collapse and thus relieves daytime sleepiness.
. which uses a mask (facial or nasal) during sleep to blow air into the upper airway. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle.and sevenfold. it is less certain that these diseases are caused by OSA. though surgery is seldom recommended. Sleep disturbance may cause difficulty concentrating. The condition is also more common in patients with a set-back chin (retrognathia). worsen short-term memory. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. such as hypothyroidism or tonsillar enlargement. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. Although CPAP does not treat the condition itself. with many patients describing sleep as unrefreshing. hypertension. Other causes of the condition include medical disorders. with the resumption of breathing usually described as a gasp or a snort. The most common symptom of OSA is sleepiness. the magnitude of the increased risk is the subject of some debate but is thought to be between three. However. and increase irritability.5 inches). which can be resolved only by weight loss or treatment of underlying conditions.
and fatigue. also known as obesity hypoventilation syndrome. leading to respiratory acidosis. Because of inadequate removal of carbon dioxide by the lungs. The pleural membranes of the
. Low blood oxygen causes the small blood vessels entering the lungs to constrict. who showed some of the same traits. an extremely obese person would exceed the optimum weight by a much larger percentage. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level. The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers.7
The Respiratory System
Pickwickian syndrome. is a complex of respiratory and circulatory symptoms associated with extreme obesity. oxygen in the blood is also significantly reduced. The elevated pressure stresses the right ventricle of the heart.
diseases of the pleura
The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. excessive fluid accumulates throughout the body (peripheral edema). In more severe instances. 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. Finally. in the space known as the pleural cavity. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers. (By some definitions. especially beneath the skin of the lower legs. ultimately causing right heart failure. thus increasing pressure in the vessels that supply the lungs.) This condition often occurs in association with sleep apnea. drowsiness. levels of carbon dioxide in the blood increase.
Pleurisy is commonly caused by infection in the underlying lung and. Mesothelioma. little or no abnormal fluid accumulates in the pleural cavity. is an inflammation of the pleura. enabling air to enter the pleural cavity. the membranes that line the thoracic cavity and fold in to cover the lungs. Treatment of pleurisy includes pain relief. In wet pleurisy. rarely. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. a cancer of the pleura.7 Diseases and Disorders of the Respiratory System
lungs are also vulnerable to perforation and spontaneous rupture. There are many causes of
. a partial or occasionally complete collapse of the lung. and treatment of the underlying disease. including tissues of the neck and head. by diffuse inflammatory conditions such as lupus erythematosus.
Pleurisy. also called pleuritis. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. In dry pleurisy. Because the pleura is well supplied with nerves.
Pleural Effusion and Thoracic Empyema
Pleural effusion. This causes spontaneous pneumothorax. fluids produced by the inflamed tissues accumulate within the pleural cavity. may occur many years after inhalation of asbestos fibres. fluid evacuation. Pleurisy may be characterized as dry or wet. or hydrothorax. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. is an accumulation of watery fluid in the pleural cavity. pleurisy can be very painful. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest.
doxycycline. Under certain conditions. The presence of both air and pus inside the pleural cavity is known as pneumothorax. and the spread of a malignant tumour from a distant site to the pleural surface. and weight loss. tissue adhesions obliterate the pleural space. As the inflammation heals. usually bacterial. coughing. infection within the pleural cavity. a tube is inserted through the chest wall into the pleural space to drain the fluid. If symptoms of pleural effusion develop. The accumulation of pus in the pleural cavity is known as thoracic empyema. shortness of breath.. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. mesothelioma). and the presence of fluid as ascertained by a chest X-ray. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. When the bronchial tree is involved in the infection. Thoracic empyema may be characterized by fever. tuberculosis. Treatment is directed at drainage of small amounts of pus through
. such as malignant disease of the pleura (i. Large pleural effusions can cause disabling shortness of breath. air may get into the pleural cavity.e. and fluid that seeps from the lungs places additional stress on the dysfunctioning heart.7
The Respiratory System
pleural effusion. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. 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 bleomycin. or pyothorax. including pneumonia. thereby preventing the accumulation of more fluid. It may also be caused by a lung abscess or some forms of tuberculosis. This condition is often the result of a microbial.
When the lung on the affected side of the chest collapses. or medical procedures.
Pneumothorax is a condition in which air accumulates in the pleural space. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. and tension pneumothorax. in tension pneumothorax air that becomes trapped in the pleural space cannot escape. which may then collapse. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. causing it to expand and thus compress the underlying lung.7 Diseases and Disorders of the Respiratory System
a needle or larger amounts through a drainage tube. after which air is sucked through the opening and into the pleural sac. In contrast to traumatic pneumothorax and spontaneous pneumothorax. Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. lung infection. or thoracoscopy (closed-lung biopsy). chest compression during cardiopulmonary resuscitation (CPR). with each breath the patient inhales. spontaneous pneumothorax. the heart. There are three major types of pneumothorax: traumatic pneumothorax. blood
. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. air and pressure accumulate within the chest. such as high-pressure mechanical ventilation. 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. Antibiotics are used to treat the underlying infection. gunshot) or other injuries to the chest wall. As a result.
diseases of the bronchi and lungs
Diseases of the bronchi and lungs are often associated with significant impairments in respiration. This leads to decreases in blood pressure. It consists of a dilatation of major bronchi. In some cases. The bronchi become chronically infected. clubbing (swelling of the fingertips and. consciousness. While small pneumothoraxes may resolve spontaneously. of the toes) may occur. and excess sputum production and episodes of chest infection are common. many of these conditions are associated with irreversible lung damage. which enables the lung to reexpand. and breathing that in turn may lead to shock and death.
Bronchiectasis is believed to usually begin in childhood. Whereas several diseases of the bronchi and lungs. Most pneumothoraxes can be treated by inserting a tube through the chest wall. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. In some cases. The disease may also develop as a consequence of airway obstruction or of undetected (and
. thereby compressing the other lung. occasionally. possibly after a severe attack of pneumonia. a catheter connected to a vacuum system is required to re-expand the lung.7
The Respiratory System
vessels. This procedure allows air to escape from the chest cavity. others may require surgery to prevent recurrences. including bronchiectasis and cystic fibrosis. In fact. may be present in childhood. and airways are pushed to the centre of the chest.
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.” without serious implications. and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. This common condition is characteristically produced by cigarette smoking. After about 15 years of smoking. Management of the condition includes antibiotics to fight lung infections. medications to dilate the airways and to relieve pain. significant quantities of mucus are coughed up in the morning.7 Diseases and Disorders of the Respiratory System
therefore untreated) aspiration into the airway of small foreign bodies. have helped control pulmonary infections and have markedly improved survival in affected persons. enzyme therapy to thin the mucus. who would formerly have died in childhood. For example. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants. But the striking increase in mortality from chronic bronchitis and emphysema that occurred after World War II in all Western countries indicated that the long-term consequences of chronic bronchitis could be serious. such as parts of plastic toys. particularly in areas of uncontrolled coal burning. In some countries chronic bronchitis is caused by daily
. Bronchiectasis may also develop as a consequence of inherited conditions. or of organic substances such as hay dust. in addition to others. many of whom. These therapies. due to an increase in size and number of mucous glands lining the large airways. of which the most important is the familial disease cystic fibrosis. now reach adult life.
For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. the ventilatory ability of the patient. Of primary importance is
. The changes are not confined to large airways. but they must be used sparingly because they can be addictive and because expectoration is necessary. the coexistence of these two conditions is known as chronic obstructive pulmonary disease. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. Unfortunately. though these produce the dominant symptom of chronic sputum production. can lead to disturbances in the distribution of ventilation and perfusion in the lung. drugs to suppress paroxysmal coughing may be necessary. Because the damage to the bronchial tree is largely irreversible. though the rate of progression generally slows. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. By the time this occurs. All these changes together. Smoking-related chronic bronchitis often occurs in association with emphysema. treatment is mainly symptomatic. is severely compromised. as measured by the velocity of a single forced expiration. Occasionally. Some people can smoke for decades without evidence of significant airway changes. consisting of expectorants and bronchodilators. It is not clear what determines the severity of these changes. in a cigarette smoker. ventilatory ability has usually been declining rapidly for some years. The mucus-producing cough will subside within weeks or months and may resolve altogether. whereas others may experience severe respiratory compromise after 15 years or less of exposure. if severe enough.7
The Respiratory System
inhalation of wood smoke from improperly ventilated cooking stoves.
7 Diseases and Disorders of the Respiratory System
the prevention of superimposed infections, either by careful watching for early signs or by using prophylactic antibiotics. Adjusting the patient’s living and working environments to the largely irreversible condition is an essential factor in treatment.
This irreversible disease consists of destruction of alveolar walls. It occurs in two forms, centrilobular emphysema, in which the destruction begins at the centre of the lobule, and panlobular (or panacinar) emphysema, in which alveolar destruction occurs in all alveoli within the lobule simultaneously. In advanced cases of either type, this distinction can be difficult to make. Centrilobular emphysema is the form most commonly seen in cigarette smokers, and some observers believe it is confined to smokers. It is more common in the upper lobes of the lung (for unknown reasons). By the time the disease has developed, some impairment of ventilatory ability has probably occurred. Panacinar emphysema may also occur in smokers, but it is the type of emphysema characteristically found in the lower lobes of patients with a deficiency in the antiproteolytic enzyme known as alpha-1 antitrypsin. Similar to centrilobular emphysema, panacinar emphysema causes ventilatory limitation and eventually blood gas changes. Other types of emphysema, of less importance than the two major varieties, may develop along the dividing walls of the lung (septal emphysema) or in association with scars from other lesions. A major step forward in understanding the development of emphysema followed the identification, in Sweden, of families with an inherited deficiency of alpha-1 antitrypsin, an enzyme essential for lung integrity. Members of affected families who smoked cigarettes
The Respiratory System
Emphysema destroys the walls of the alveoli of the lungs, resulting in a loss of surface area available for the exchange of oxygen and carbon dioxide during breathing. This produces symptoms of shortness of breath, coughing, and wheezing. In severe emphysema, difficulty in breathing leads to decreased oxygen intake, which causes headaches and symptoms of impaired mental ability. Encyclopædia Britannica, Inc.
commonly developed panacinar emphysema in the lower lobes, unassociated with chronic bronchitis but leading to ventilatory impairment and disability. Intense investigation of this major clue led to the “protease-antiprotease” theory of emphysema. It is postulated that cigarette smoking either increases the concentration of protease enzymes released in the lung (probably from white blood cells) or impairs the lung’s defenses against these enzymes or both. Although many details of the essential biochemical steps at the cellular level remain to be clarified, this represents a major step forward in understanding a disease whose
7 Diseases and Disorders of the Respiratory System
genesis was once ascribed to overinflation of the lung (like overdistending a bicycle tire). Chronic bronchitis and emphysema are distinct processes. Both may follow cigarette smoking, however, and they commonly occur together, so determination of the extent of each during life is not easy. In general, significant emphysema is more likely if ventilatory impairment is constant, gas transfer in the lung (usually measured with carbon monoxide) is reduced, and the lung volumes are abnormal. Development of high-resolution computerized tomography has greatly improved the accuracy of detection of emphysema. Some people with emphysema suffer severe incapacity before age 60. Thus, emphysema is not a disease of the elderly only. An accurate diagnosis can be made from pulmonary function tests, careful radiological examination, and a detailed history. The physical examination of the chest reveals evidence of airflow obstruction and overinflation of the lung, but the extent of lung destruction cannot be reliably gauged from these signs, and therefore laboratory tests are required. The prime symptom of emphysema, which is always accompanied by a loss of elasticity of the lung, is shortness of breath, initially on exercise only, and associated with loss of normal ventilatory ability and increased obstruction to expiratory airflow. The expiratory airflow from a maximum inspiration is measured by the “forced expiratory volume in one second,” or FEV1, and is a predictor of survival of emphysema. Chronic hypoxemia (lowered oxygen tension) often occurs in severe emphysema and leads to the development of increased blood pressure in the pulmonary circulation, which in turn leads to failure of the right ventricle of the heart. The symptoms and signs of right ventricular failure include swelling of the ankles (edema) and engorgement of the neck veins. These are portents of advanced lung disease in this condition. The
The Respiratory System
hypoxemia may also lead to an increase in total hemoglobin content and in the number of circulating red blood cells, as well as to psychological depression, irritability, loss of appetite, and loss of weight. Thus, the advanced syndrome of chronic obstructive lung disease may cause such shortness of breath that the afflicted person has difficulty walking, talking, and dressing, as well as numerous other symptoms. The slight fall in ventilation that normally accompanies sleep may exacerbate the failure of lung function in chronic obstructive lung disease, leading to a further fall in arterial oxygen tension and an increase in pulmonary arterial pressure. Unusual forms of emphysema also occur. In one form the disease appears to be unilateral, involving one lung only and causing few symptoms. Unilateral emphysema is believed to result from a severe bronchiolitis in childhood that prevented normal maturation of the lung on that side. “Congenital lobar emphysema” of infants is usually a misnomer, since there is no alveolar destruction. It is most commonly caused by overinflation of a lung lobe due to developmental malformation of cartilage in the wall of the major bronchus. Such lobes may have to be surgically removed to relieve the condition. Bullous emphysema can occur in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung tissue. This disease most commonly occurs between ages 15 and 30 and usually is not recognized until a bullous air space leaks into the pleural space, causing a pneumothorax.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by the
it is increasingly recognized that COPD has secondary associations. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. which is replaced by holes characteristic of emphysema. Therefore. either bacterial or viral. Frequent exacerbations.7 Diseases and Disorders of the Respiratory System
combination of signs and symptoms of emphysema and bronchitis. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. which gives rise to symptoms of bronchitis. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. particularly lung cancer. antibiotics. particularly if severe enough to warrant hospital admission. Sources of noxious particles that can cause COPD include tobacco smoke. are not always required. and each year about 30. including muscle weakness and osteoporosis. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). air pollution. Coughing up blood is not a feature of COPD and when present raises concern about a second. tobacco-related condition. Although primarily a lung disease. and the burning of certain fuels in poorly ventilated areas. It is a common disease. Exacerbations are triggered by infection. indicate a poor prognosis.000 people in the United States die from COPD. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). and by a tendency for excessive mucus production in the airway. which causes increased lung volume and manifests as breathlessness. which
.000 people in the United Kingdom and roughly 119. which work against bacteria. COPD is distinguished pathologically by the destruction of lung tissue.
inability of the heart to function adequately). especially for patients with frequent exacerbations. In COPD patients with low blood–oxygen levels. high blood pressure. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. or cardiac insufficiencies (i. Some COPD patients do not find oxygen attractive. This should be followed by a community/home maintenance program or by repeat courses every two years. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. A six.. including noninvasive ventilation and surgical options (i. Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD. which leads to further difficulties in mobility. oxygen is extremely flammable. Inhaled corticosteroids are commonly prescribed. Active congestion of the lungs is caused by
Lung congestion is characterized by distention of blood vessels in the lungs and filling of the alveoli with blood as a result of an infection. since they need to use it for 16 hours each day to derive benefit..e. In addition. Specialized centres can offer treatments for patients with advanced disease.e. lung transplantation and lung-volume reduction). bronchodilators)..e.7
The Respiratory System
can be accomplished in most cases by cessation of smoking.to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy.
narrowing of the valve between the upper and lower chambers in the left side of the heart. In
. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. The major complication arises in mild cases of pneumonia. and blood escapes through the capillary wall into the alveoli. and the skin takes on a bluish tint as the disease progresses. The walls of the alveoli also thicken and gas exchange is greatly impaired. Inflammatory edema results from influenza or bacterial pneumonia. Passive congestion is due either to high blood pressure in the capillaries. 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. The affected person shows difficulty in breathing. and the precipitating causes may somewhat differ. liquids. although there is usually enough unaffected lung tissue for respiration. The alveolar walls and the capillaries in them become distended with blood. The blood pressure becomes high in the alveolar capillaries. causes chronic passive congestion. flooding them.7 Diseases and Disorders of the Respiratory System
infective agents or irritating gases. there is a bloody discharge. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. Blood accumulates in the lower part of the lungs. Mitral stenosis. or to relaxation of the blood capillaries followed by blood seepage. and they begin to distend. caused by a cardiac disorder. Eventually the pressure becomes too great. and particles. rather than whole blood. when the remaining functioning tissue becomes infected. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue.
Dr. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6241)
The Respiratory System
X-ray showing lung congestion caused by congestive heart failure.
the blood pressure rises and edema ensues. or air sacs. and heavy. The term atelectasis can also be used to describe the collapse of a previously inflated lung. with deep gurgling rattles in the throat. because he or she is too weak to clear the fluids. and obstructive. These infants usually suffer from a disorder called respiratory distress syndrome. It may take only one or two hours for two to three quarts of liquid to accumulate. This is typically caused by a failure to develop surface-active material
. enlarged. for unknown reasons. The lungs become pale. The term is derived from the Greek words atele s and ektasis. There are three major types of atelectasis: adhesive. their lungs show areas in which the alveoli.
Atelectasis is characterized primarily by the absence of air in the lungs. wet. and. 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
mechanical edema the capillary permeability is broken down by the same type of heart disorders and irritants as in congestion. A person with pulmonary edema experiences difficulty in breathing. either partially or fully. compressive. the person may actually drown in the lung secretions. are not expanded with air. Acute cases can be fatal in 10 to 20 minutes. After an operation. Excessive irradiation and severe allergic reactions may also produce this disorder. literally meaning “incomplete expansion” ¯ in reference to the lungs. if too great a volume of intravenous fluids is given. It can occur. after reinflation of a collapsed lung. The person’s skin turns blue. because of specific respiratory disorders. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed.
Dr. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242)
.7 The Respiratory System
X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis.
they can be pushed out of the bronchi by coughing or strong exhalation of air. or elevation of the diaphragm. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. Mucous plugs can result that cause atelectasis. displacement of the heart toward the affected side. When a person undergoes surgery. absence of respiratory movement on the side involved. and bacterial cells. and consolidation of the lungs into a smaller mass. Other causes of obstruction include tumours or infection. If a lung remains collapsed for a long period. and the muscles beneath the lungs may be weakened. The symptoms in extreme atelectasis include low blood oxygen content. if these secretions become too abundant. Treatment for infants with this syndrome includes replacement therapy with surfactant. which frequently enter with inhaled air. 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. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out. Local pressure can result from tumour growths. After abdominal surgery. soot. It may also occur as a complication of abdominal surgery. causing air trapped in the alveoli to be slowly absorbed by the blood. The air passageways in the lungs normally secrete a mucous substance to trap dust. the anesthetic stimulates an increase in bronchial secretions. Collapse is complete if the force is uniform or is partial when the force is localized. an enlarged heart. and respiratory function cannot be restored. Treatment for obstructive and compressive
. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. which manifests as a bluish tint to the skin.7 Diseases and Disorders of the Respiratory System
(surfactant) in the lungs. Generally.
however. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac.
. The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. 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). shoulders.7
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atelectasis is directed toward removal of any obstruction or compressive forces.
Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. When pain is present it indicates pleural involvement. infarcts that occur deep inside the lungs produce no pain. If the lung is congested. or air bubbles in the bloodstream (both of these are instances of embolism). or inadequately supplied with air. The section of dead tissue is called an infarct. Pain is most severe on inhalation. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. The pain may be localized around the rib cage. and neck. Ordinarily. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. lung infarctions can follow blockage of a blood vessel. such blockages fail to cause death of tissue because the blood finds its way by alternative routes. infected. near the muscular diaphragm that separates the chest cavity from the abdomen. or it may be lower. when the lungs are healthy.
moderate difficulty in breathing.
Cystic fibrosis.e. by the mid-1980s. fever. Cystic fibrosis was not recognized as a separate disease until 1938 and was then classified as a childhood disease because mortality among afflicted infants and children was high. the chief symptom of which is the production of a thick. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. sticky mucus that clogs the respiratory tract and the gastrointestinal tract.000 live births in these populations and is particularly concentrated in people of northwestern European descent. is an inherited metabolic disorder. and a dull sound heard when the chest is tapped. only persons inheriting a defective gene from both parents will manifest the disease). when both
. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. increased heartbeat. The disorder was long known to be recessive (i.000 live births) and is very rare in people of Asian ancestry. The disease has no manifestations in heterozygotes (i. those individuals who have one normal copy and one defective copy of the particular gene involved). The dead tissue is replaced by scar tissue. However. However. It is much less common among people of African ancestry (about 1 per 17.. coughing. pleural rubbing.e. It is estimated to occur in 1 per 2. diminished breath sounds. also known as mucoviscidosis. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). Infarcts that do not heal within two or three days generally take two to three weeks to heal.7 Diseases and Disorders of the Respiratory System
The symptoms of infarcts are generally spitting up of blood..
The thick. chloride and sodium ions accumulate within cells. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. and the progressive loss of lung function are the major manifestations of lung disease. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. lies in the middle of chromosome 7 and encodes a protein of the same name. Chronic cough.. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. one out of four of their offspring will have the disease. often with Staphylococcus aureus or Pseudomonas aeruginosa. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. sticky mucus accumulates in the lungs. greasy. recurrent pneumonia. or CFTR. This results in chronic respiratory infections. About 10
. they may expect that. In 1989 the defective gene responsible for cystic fibrosis was isolated. foul-smelling stools are often the first signs of cystic fibrosis. called cystic fibrosis transmembrane conductance regulator. In the digestive system. the mucus-secreting and sweat glands) in the respiratory and digestive systems. which is the most common cause of death of persons with cystic fibrosis. on the basis of chance. The gene.7
The Respiratory System
parents are heterozygous. As a result. Within the cells of the lungs and gut. the CFTR protein transports chloride across cell membranes and regulates other channels. Bulky. designated CFTR. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet.g. 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. plugging the bronchi and making breathing difficult.
The high salt content in perspiration is the basis for the “sweat test. These tests are effective in the identification of adult carriers (heterozygotes).” which is the definitive diagnostic test for the presence of cystic fibrosis. sometimes in aerosolized form. lung transplantation may be considered. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories.7 Diseases and Disorders of the Respiratory System
percent of infants with cystic fibrosis have intestinal obstruction at birth due to very thick secretions. Many patients with cystic fibrosis regularly take antibiotics. In addition. are given to thin mucus. These agents may be administered by means of an inhaler or a nebulizer. and fat. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. In addition.
. protein. as well as in the identification of newborns who may be at risk for the disorder. Medications such as dornase alfa. In severe cases. Mutations associated with cystic fibrosis can be detected in screening tests. facilitating its clearance from the lungs through coughing. who may pass a mutation on to their offspring. making it easier for patients to breathe. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. which is powered by a compressor that sprays aerosolized drug into the airways. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. a recombinant form of the enzyme deoxyribonuclease. in order to fight lung infections.
and the outcomes of clinical trials are marked by steady improvement. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. and adenovirus associated virus. Gene therapy first emerged as a potential form of treatment in 1990. However. cationic liposomes. The latter. gene therapy for cystic fibrosis has undergone significant refinement. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. These vectors were then transfected into the cultured cells. This first trial initially appeared to be successful. including lung inflammation and signs of viral infection. As a result. the patients experienced severe side effects. which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. 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. has proved particularly effective in laboratory studies using human lung tissue. Since the 1990s. However. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene.
. Delivery systems under investigation include cationic polymer vectors. which subsequently incorporated the normal genes into their DNA. the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. since increased expression of the CFTR protein was observed shortly after treatment. the natural defense systems of the lungs and airways have proved significant obstacles to cellular uptake of the viral vector carrying the normal CFTR gene.7
The Respiratory System
Among the most promising treatments under investigation for cystic fibrosis is gene therapy.
Some individuals have clubbed fingertips and toes. Other common changes are enlargement of the lymph
. Some individuals may benefit from single or double lung transplantation. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs. called rales or “Velcro crackles. Sharp crackling sounds. in different organs.7 Diseases and Disorders of the Respiratory System
Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. A dry cough is common as well. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. or granulomas. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest.
Sarcoidosis and Eosinophilic Granuloma
Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. however. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. there is no effective treatment. pulmonary function testing shows a reduction in lung volume. In addition.” are heard through a stethoscope applied to the back in the area of the lungs. The average duration of survival from diagnosis is four to six years. The disease most commonly manifests between ages 50 and 70. with insidious onset of shortness of breath on exertion. some people live 10 years or longer. the lung is commonly involved. Aside from administration of supplemental oxygen.
Eosinophilic granuloma. The kidney is not commonly involved. but often there is little interference with lung function. When too much surfactant is released from the alveolar cells. 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. Occasionally. The disease usually remits without treatment within a year or so. also known as histiocytosis X. leading to signs of involvement in the affected area. Evidence of granulomas in the lung may be visible. and liver dysfunction. but in a small proportion of cases it progresses. Eosinophilic granuloma is a lung condition that may spontaneously “burn out.7
The Respiratory System
glands at the root of the lung. a subgroup of immune cells. It causes lesions in lung tissue and sometimes also in bone tissue. nerve sheaths are inflamed. or when the lung fails to remove the
. is a disease associated with the excess production of histiocytes. The alveoli are air sacs.” leaving the lung with some permanent cystic changes. The gas molecules must pass through a cellular wall.
Pulmonary Alveolar Proteinosis
Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. inflammation in the eye. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. minute structures in the lungs in which the exchange of respiratory gases occurs. a complex mixture of protein and lipid (fat) molecules. but some changes in blood calcium levels occur in a small percentage of cases. skin changes. the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. Although its cause is unknown.
Treatment involves removal of the material by a rinsing out of the lungs (lavage). gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. The skin becomes tinged with blue in the most serious cases. The precipitating cause of the disease is unknown. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. One lung at a time is rinsed with a saltwater solution introduced through the windpipe.
Immunologic Conditions of the Lung
The lung is often affected by generalized diseases of the blood vessels. but its cause is not fully understood. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. but rarely so. if treated. The disease can exist without causing symptoms for considerable periods. and it is often accompanied by chest pain and a dry cough. it is sometimes fatal. The fluids drawn back out of the lungs have been found to have a high content of fat. Pulmonary hemorrhage also occurs as part of a condition
. but subsequent treatments are often necessary. and spontaneous improvement has been known to occur. is an important cause of pulmonary blood vessel inflammation. X-rays most frequently show evidence of excess fluids in the lungs. Sometimes the lesions totally clear up after one procedure.7 Diseases and Disorders of the Respiratory System
surfactant. Persons affected are usually between ages 20 and 50. an acute inflammatory disease of the blood vessels believed to be of immunologic origin. Wegener granulomatosis. The condition has been successfully treated by exchange blood transfusion. There may also be general fatigue and weight loss.
by the use of pulmonary function tests. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. and the lung parenchyma may be involved. Lung cancer was first described by doctors in the mid-19th century. accurate diagnosis has been much improved by refinements in radiological methods. a slowly obliterative disease of small airways (bronchiolitis) occurs.7
The Respiratory System
known as pulmonary hemosiderosis. In women.
. These conditions have only recently been recognized and differentiated. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. following breast cancer. The common condition of rheumatoid arthritis may be associated with scattered zones of interstitial fibrosis in the lung or with solitary isolated fibrotic lesions. In the 21st century. More rarely. which is also believed to have an immunologic basis. it has surpassed breast cancer.
Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs. leading finally to respiratory failure. In the early 20th century it was considered relatively rare. resulting in an estimated 1. however. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. lung cancer is the second leading cause of death from cancer globally. In the United States. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. Pleural effusions may occur. lung cancer emerged as the leading cause of cancer deaths worldwide.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.
The most common symptoms include shortness of breath. bloody sputum. tar refiners. Tumours can begin anywhere in the lung.400 deaths from lung cancer in nonsmoking adults in the United States each year. In cases where the cancer has spread beyond the lungs. as do some workers in hydrocarbon-related processing. unexplained weight loss. In countries with a prolonged history of cigarette smoking. visible lumps. jaundice. and susceptibility to lower respiratory infections. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. small-cell
. The risk is also greater for those who started smoking at a young age. the tumour’s type and degree of invasiveness are determined. Of the two basic forms. secondhand smoke accounts for an estimated 3. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. Types of Lung Cancer Once diagnosed. welders. chest pain. and roofers. Heavy smokers have a greater likelihood of developing the disease than do light smokers. a persistent cough or wheeze. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body.7 Diseases and Disorders of the Respiratory System
Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. Lung cancer is rarely caused directly by inherited mutations. such as coal processors. Uranium and pitchblende miners. or bone pain may occur. and workers exposed to halogenated ethers also have an increased incidence. between 80 and 90 percent of all cases are caused by smoking. According to the American Cancer Society. chromium and nickel refiners. Other risk factors include exposure to radon gas and asbestos.
peripheral bronchi. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. It is characterized by cells that are small and round. pleura. About 10 percent of all lung cancers are large-cell carcinomas. the survival rate is very low. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. and large-cell carcinoma. Cancer cells may be detected in sputum. Diagnosis. oval. or shaped like oat grains. This tumour is characterized by flat. Small-cell carcinoma (SCLC).7
The Respiratory System
carcinoma accounts for 20 to 25 percent of all cases and non-small-cell carcinoma is responsible for the remainder. Tumours often originate in the smaller. 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. also called epidermoid carcinomas. also called oat-cell carcinoma. Treatment. scalelike cells. SCLC is the most aggressive type of lung cancer. but it is the most common type of lung cancer in the United States. and it often develops in the larger bronchi of the central portion of the lungs. 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.or column-shaped. and Prevention Lung cancers are often discovered during examinations for other conditions. adenocarcinoma. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. and they form structures that resemble glands and are sometimes hollow. Cells of adenocarcinoma are cube. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. Because it tends to spread quickly before symptoms become apparent. is rarely found in people who have never smoked.
. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas.
positron emission tomography (PET) scans. computed tomography (CT) scans. and magnetic resonance imaging (MRI). Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. treatments for lung cancer include surgery. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. Surgery involves the removal of a cancerous segment (segmentectomy). The choice of treatment depends on the patient’s general health. and the type of cancer. For example. For this reason. As with most cancers. Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or
.7 Diseases and Disorders of the Respiratory System
a needle biopsy may be used to remove a sample of lung tissue for analysis. the five-year survival rate is about 50 percent. Noninvasive methods include X-rays. chemotherapy. a lobe of the lung (lobectomy). the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. 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. Lung surgery is serious and can lead to complications such as pneumonia or bleeding. lung cancer has a poorer prognosis than many other cancers. which can identify mutations that render some lung cancers susceptible to specific drugs. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. or the entire lung (pneumonectomy). the stage or extent of the disease. Even when it is detected early. and radiation.
Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). fatigue. but these chemicals also attack normal cells to varying degrees. or additional damage to the lungs.
diseases of the MediastinuM and diaphragM
The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. together with the many important structures situated within it. causing side effects that are similar to radiation therapy. which relies on heat derived from microwave energy to kill cancer cells. asbestos. Chemotherapy uses chemicals to destroy cancerous cells. and other airborne carcinogens also lowers risk. 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. The probability of developing lung cancer can be greatly reduced by avoiding smoking. particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the
. Side effects include vomiting. Enlargement of lymph glands in this region is common. Smokers who quit also reduce their risk significantly. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. diarrhea.7
The Respiratory System
following surgery to destroy small amounts of cancerous tissue. Testing for radon gas and avoiding exposure to coal products.
When the alveoli of the lungs rupture because of traumatic injury or lung disease. the extra gas pressure is relieved by exhaling. when he or she begins to ascend again. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. there is no difficulty. main bronchi. One pathway that the air can follow is through the lung tissue into the mediastinum. and the lungs begin to expand because the air inside has less pressure to contain it. This usually occurs as a result of lung rupture. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. the external pressure decreases. If the diver holds his or her breath. Air bubbles can then enter the veins and capillaries of the circulatory system directly. and collapse blood vessels vital to circulation. making breathing difficult. the external pressure upon his or her body increases. The pressure may cause intense pain beneath the rib cage and in the shoulders. the expanding air may compress the respiratory passageways.7 Diseases and Disorders of the Respiratory System
heart and central blood vessels. which do not permit sufficient release of air. If the diver breathes normally or exhales as he or she ascends at a moderate rate. the released air seeks an area of escape. This area contains the heart. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. causing an air embolism. the lungs become overinflated and rupture. rises too rapidly. and the trachea. or scar tissue. The air the diver breathes is more dense and concentrated than the air breathed on the surface. or they can travel through the lung tissue to other areas of the body. major blood vessels. While the diver remains deeply submerged. however.
. mucus plugs. or has respiratory obstructions such as cysts. Air trapped in the mediastinum expands as the diver continues to rise. As a diver descends.
For example. although some shortness of breath on exertion is often present. diaphragmatic fatigue may limit the exercise capability of affected persons. bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. and shallow breathing to unconsciousness. If there is respiratory or circulatory distress. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. In some persons the diaphragm may be incompletely formed at birth. as occurs in emphysema. In cases in which the symptoms are not severe. the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. and cyanosis (blue colouring of the skin). Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. respiratory failure.
The Respiratory System
The symptoms of mediastinal emphysema may range from pain under the breastbone. especially when the subject is recumbent (lying down). In many cases the cause of the paralysis cannot be determined. this can lead to herniation of the abdominal viscera through the diaphragm. The function of the diaphragm may be compromised when the lung is highly overinflated. shock. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air. the air will be absorbed by the body.
Respiratory function can be severely compromised by a variety of other conditions. leading to cancer and substantial loss of lung function.
. For most affected persons. such as respiratory distress syndrome. causes respiratory disease in otherwise healthy workers. affected persons are highly sensitive to substances such as dust or pollen. the lungs are exposed to the outside environment.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. Carbon monoxide poisoning. decompression sickness. reducing exposure to the irritant relieves the symptoms of their condition. and drowning are other examples of acute conditions that can result in respiratory failure. and. In occupational disease.
allergic lung diseases
There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. First. however. In some cases of occupational exposure. hence. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. such as asbestos and coal dust. altitude sickness. traumatic conditions. In the case of allergies. severe respiratory disease may ensue. exposure to harmful irritants. For example. many of which are acute in nature.
second. causing episodes of wheezing. such as pollen. In adults. however. women are affected more often than men. When asthma develops in childhood. dust mites. aspirin. The most common and most important of these is asthma. and. boys being affected more often than girls. and grains. stress may exacerbate symptoms. In addition. and breathlessness that range in severity from mild to life-threatening. asthma may develop in response to allergens. that may induce an allergic reaction. chest tightness. Adult asthma is sometimes linked to exposure to certain materials in the workplace.7
The Respiratory System
particles of foreign substances such as pollen may be deposited directly in the lungs. and exercise may cause it as well.
Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. which may be involved in any general inflammatory response. coughing. such as chemicals. Asthmatic episodes may begin suddenly or may take days to develop. but viral infections. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. the lung contains a very large vascular bed. it is often associated with an inherited susceptibility to allergens— substances. approximately half of all cases occur in persons younger than age 10. nasal polyps. Among adults. or animal dander. or sinusitis. 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. weather conditions. Adults who develop asthma may also have chronic rhinitis. wood dusts. Although an initial episode can occur at any age. These substances provoke both allergic and nonallergic forms of the disease. third. In
and severe persistent.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
During normal breathing. which results in tightening of the airways. which can be divided into four categories: mild intermittent. symptoms will subside if the causative agent is removed from the workplace. Encyclopædia Britannica. moderate persistent. Asthma is classified based on the degree of symptom severity. smooth muscles that surround the airways spasm. in general
. mild persistent. air is obstructed from circulating freely in the lungs and cannot be expired. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. 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. Consequently. Although the mechanisms underlying an asthmatic episode are not fully understood. Inc.
most of these cases. narrower passages (bronchioles) and finally into the tiny. During an asthma attack.
g. which suppress inflammation. Agents that block enzymes called phosphodiesterases. which are leukotriene modifiers. which are anti-inflammatory medications often prescribed for children. and leukotriene modifiers. and zileuton and zafirlukast. Long-term control medications include corticosteroids. which are the most potent and effective anti-inflammatory medications available. which are bronchodilators. which relax smooth muscle constriction and open the airways. long-acting beta2-agonists and methylxanthines (e. which are involved in mediating airway constriction and inflammation. These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). are in clinical trials. Asthma medications are categorized into three main types: anti-inflammatory agents. swelling and inflammation of the bronchial tubes. or systemic corticosteroids. The obstruction of airflow may resolve spontaneously or with treatment. These
. These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi. air is inspired but cannot be expired). The inflamed. bronchodilators.. cromolyn sodium and nedocromil. which interrupt the chemical signaling within the body that leads to constriction and inflammation. and excessive secretion of mucus into the airways. such as shortacting beta2-agonists and ipratropium bromide.7
The Respiratory System
it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system. Quick-relief medications may include bronchodilators. or they may be used to provide rapid relief from constriction of airways (quick-relief medications). A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. theophylline).e. mucus-clogged airways act as a one-way valve (i..
In addition to managing asthma with medications. However. smoking. Reasons for this dramatic surge in asthma cases.
. exposure to secondhand smoke. Further investigation of this “helminthic therapy” in larger sample populations is under way. in many underdeveloped tropical regions of the world. particularly among children. A person with this condition must be hospitalized to receive oxygen and other treatment. Air pollution.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
drugs are designed to be long-lasting—administered once per day via inhalation—and are expected to be safer than traditional medications. and even cockroaches have been blamed for the increase. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. In those areas. crowded living conditions. The ability to recognize the early warning signs of an impending episode is important. are not entirely clear. can relieve symptoms of allergy and asthma. very few people are affected by allergies or asthma. millions of people are infected with Necator americanus. the number of asthma cases has increased steadily. In developed countries and especially in urban areas. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. A prolonged asthma attack that does not respond to medication is called status asthmaticus. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma. too few to cause hookworm disease. which may cause cardiovascular damage. Today asthma affects more than 7 percent of children and about 9 percent of adults. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. a species of hookworm.
Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. Symptoms may be aggravated by emotional factors. may give rise to asthma. is a common seasonal condition caused by allergy to grasses and pollens. 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. Seasonally recurrent bouts of sneezing. desensitization by injections of an extract of the causative pollen administered once or twice a week for one or more years. Although not yet successfully confirmed. nasal congestion. also known as allergic rhinitis. In allergic persons contact with pollen releases histamine from the tissues. 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). studies have indicated that only one vaccine. like other allergic diseases. Hay fever. such as dermatitis or asthma.7
The Respiratory System
There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. chiefly those depending upon the wind for cross-fertilization. pertussis vaccine. Antibiotics may also interfere with immune development. which irritates the small blood vessels and mucus-secreting glands. In a reverse scenario.
. The most effective long-term treatment is immunotherapy. shows a familial tendency and may be associated with other allergic disorders.
Hay fever. such as ragweed in North America and timothy grass in Great Britain. and tearing and itching of the eyes caused by allergy to the pollen of certain plants.
. Louise K. Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
Giant ragweed (Ambrosia trifida) is a common cause of hay fever.
granulomas. A similar group of diseases occurs in those with close contact with birds. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. Farmer’s lung is common in Wisconsin. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. This causes an acute febrile illness with a characteristically fine opacification (clouding. after
. and canaries. and in France. Airflow obstruction in small airways is present. on the eastern seaboard of Canada. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). these represent different kinds of allergic responses to proteins from birds. Variously known as pigeon breeder’s lung or bird fancier’s lung. in the west of England. with inflammation of the smaller bronchioles. If untreated.7
The Respiratory System
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. or becoming opaque) in the basal regions of the lung on the chest radiograph. In more chronic forms of the condition. may be found in the lung. with shortness of breath persisting after the radiographic changes have disappeared. alveolar wall edema. budgerigars (parakeets). particularly proteins contained in the excreta of pigeons. the condition may become chronic. and there may be measurable interference with diffusion of gases across the alveolar wall. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). One of these illnesses is the so-called farmer’s lung. or aggregations of giant cells.
Runk/Schoenberger from Grant Heilman
exposure to redwood sawdust. 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. but sometimes the precise agent cannot be identified. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. or in response to a variety of other agents. It is occasionally attributable to Aspergillus.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
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
Among inorganic dusts. progressing to more serious breathing impairment. usually over a prolonged period of time. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. The type and severity of disease depends on the composition of the dust. and cough. produce grave reactions. encountered in numerous occupations. of the lung. Inhaled dust collects in the alveoli. beryllium.7
The Respiratory System
irritants. barium. and coal dusts are other inorganic substances known to produce pneumoconiosis. iron. the toxic effects of certain types of dust. As little as 5 or 6 grams (about 0. and the clinical symptoms of pneumoconiosis are manifested.2 ounce) in the lung can produce disease. is the most common cause of severe pneumoconiosis. silica. and infections of the already damaged lung can accelerate the disease process. If enough scar tissue forms. lung function is seriously impaired. and aluminum dusts can cause a more severe pneumoconiosis. clay. Graphite. small quantities of some substances. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. Asbestos. tin. while milder irritants produce symptoms of lung disease only with massive exposure. chronic bronchitis. and emphysema in the most severe cases. or air sacs. although silica exposure is also involved in many cases. often after relatively brief
. The total dust load in the lung. the early symptoms of mild pneumoconioses include chest tightness. shortness of breath. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. chromate. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. Typically. notably silica and asbestos.
even in previously nonallergic persons. impeding exhalation. and buffing. Prolonged exposure to organic dusts such as spores of molds from hay. (Silica is the chief mineral constituent of sand and of many kinds of rock. sugarcane. and barley can produce lung disease through a severe allergic response within a few hours of exposure.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
exposure to massive amounts of dust. the patient may recover completely or may suffer from chronic bronchitis or asthma. and workers whose jobs involve grinding. sandblasting. malt. and their irritant effect may cause large amounts of fluid to accumulate in the lungs. stimulate histamine release.) The disease occurs most commonly in miners. quarry workers. mushrooms. or hemp that. The chemicals themselves may scar the delicate lung tissues. stonecutters. Once exposure to the chemical ceases. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. and it remains one of the most common dust-induced respiratory diseases in the developed world. having been recognized in knife grinders and potters in the 18th century. and chloride. ammonia. when inhaled. which are quickly absorbed by the lining of the lungs. acid. Brown lung disease in textile workers is also a form of pneumoconiosis. Chemical irritants that have been implicated in lung disease include sulfur dioxide. polishing. nitrogen dioxide.
Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. Histamines cause the air passages to constrict. Asbestosis has also been associated with cancers of the lung and other organs. caused by fibres of cotton. Silicosis is one of the oldest industrial diseases. tunnelers. flax. The
. In most instances.
and particles of one to three microns do the most damage. however. though this has changed with the availability of drug therapies for that disease. also known as coal-worker’s pneumoconiosis. and gas exchange is poor. control of the disease lies mainly in prevention. In the actual disease process.000. the openings to the lungs.7
The Respiratory System
disease rarely occurs with exposures to concentrations of less than 6. and.000 per litre) of air. These whorls of fibrous tissue may spread to involve the area around the heart. The symptoms of silicosis are shortness of breath that is followed by coughing. called macrophages. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. These symptoms are all related to a fibrosis that reduces the elasticity of the lung.0004 inch) in diameter penetrate to the finer air passages of the lungs. is a respiratory disorder caused by repeated inhalation of
. Lung volume is reduced. Silica particles. Only very small silica particles less than 10 microns (0. and the abdominal lymph nodes. emphysema. and weakness. that serve to protect the body from bacterial invasion. cannot be digested by the macrophages and instead kill them. In the past a large proportion of sufferers of silicosis died of tuberculosis. and pneumonia. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses. Silicosis predisposes a person to tuberculosis. difficulty in breathing. since there is no effective treatment. There is no cure for silicosis.
Black lung.000 particles of silica per cubic foot (about 210. 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.
Symptoms usually appear only after 10 to 20 years of exposure to coal dust. first described lung disease in coal miners in the 16th century. which produces characteristic changes in the lungs that can be identified in chest X-rays and that can impair lung function at an early stage. which causes similar symptoms. The disease is most commonly found among miners of hard coal. however. a German mineralogist. It may be the best known occupational illness in the United States. but it also occurs in soft-coal miners and graphite workers. It is not clear. brake linings. and the extent of disease is clearly related to the total dust exposure. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to
Asbestosis and Mesothelioma
The widespread use of asbestos as an insulating material during World War II. Georgius Agricola. The first disease recognized to be caused by asbestos was asbestosis. ceiling tiles. and as a fire protectant sprayed inside buildings. There is strong evidence that tobacco smoking aggravates the condition. Onset of the disease is gradual. led to a virtual epidemic of asbestos-related disease 20 years later. and it is now widely recognized. The early stages of the disease (when it is called anthracosis) usually have no symptoms. as coal dust often is contaminated with silica. and later in flooring. tuberculosis is also more common in victims of black lung.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
coal dust over a period of years. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. whether coal itself is solely responsible for the disease.
The Respiratory System
thickening of the pleura. These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. is inhaled than if chrysotile is inhaled. but survival after diagnosis is less than two years. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer. Asbestos has been suspected to play a role in stimulating certain cellular events. although in occasional cases pleuritis is very aggressive and thus may produce symptoms. there was a major increase in the risk for lung cancer. As far as is known. It is not yet understood exactly why asbestos devastates the tissues of the lungs. Not all types of asbestos are equally dangerous. All
. Malignant mesothelioma is rare and unrelated to cigarette smoking. The risk of mesothelioma in particular appears to be much higher if crocidolite. a blue asbestos that comes from South Africa. inhalation of asbestos remains a significant risk for the workers removing the material. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. But exposure to any type of asbestos is believed to increase the risk of lung cancer. thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. especially when associated with cigarette smoking. all the respiratory changes associated with asbestos exposure are irreversible. and. In most cases. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. when both cigarette smoking and asbestos exposure occurred.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.
Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing
The Respiratory System
beryllium alloys, and a slow-developing chronic disease occurring in scientific and industrial workers who are exposed to beryllium-containing fumes and dust. The acute disease involves both skin and lungs, causing a burning rash, eye irritation, nasal discharge, a cough, and chest tightness. The skin disease is caused by direct contact with beryllium salts and the lung disease by inhalation of metal dust or beryllium compounds. Most of those affected by acute berylliosis recover within a few months, but a small number of patients develop a highly fatal inflammation of the lung within 72 hours after a brief, massive exposure to beryllium. The chronic disease may occur more than 15 years after exposure, although the later it develops, the milder it is likely to be. It generally causes shortness of breath, especially after exercise, exhaustion, and a dry cough and can produce a permanent, though moderate, disability.
Byssinosis, or brown lung, is a respiratory disorder caused by inhalation of an endotoxin produced by bacteria in the fibres of cotton, flax, hemp, and other textiles. Byssinosis is common among textile workers, who often inhale significant amounts of cotton dust. Cotton dust may stimulate inflammation that damages the normal structure of the lung and causes the release of histamine, which constricts the air passages. As a result, breathing becomes difficult. Over time the dust accumulates in the lung, producing a typical discoloration that gives the disease its common name. Byssinosis was first recognized in the 17th century and was widely known in Europe and England by the early 19th century. Today it is seen in most cotton-producing
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
regions of the world. Several years of exposure to cotton dust are needed before byssinosis develops, and workers with lower grade disease usually recover completely upon leaving the industry or moving into an area with less dust. Persons with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure continues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Because cotton is by far the most common cause of byssinosis, this form of the condition has been variably known as cotton-dust asthma and cotton-mill fever.
Respiratory Toxicity of Industrial Chemicals
Toluene diisocyanate, used in the manufacture of polyurethane foam, may cause occupational asthma in susceptible individuals at very low concentrations. In higher concentrations, such as may occur with accidental spillage, it causes a transient flulike illness associated with airflow obstruction. Prompt recognition of this syndrome has led to modifications in the industrial process involved. Although the acute effects of exposure to many of these gases and vapours are well documented, there is less certainty about the long-term effects of repeated low-level exposures over a long period of time. This is particularly the case when the question of whether work in a generally dusty environment has contributed to the development of chronic bronchitis or later emphysema. In other words, whether such nonspecific exposures increase the risk of these diseases in cigarette smokers. Many chemicals can damage the lung in high concentration: these include oxides of nitrogen, ammonia,
The Respiratory System
chlorine, oxides of sulfur, ozone, gasoline vapour, and benzene. In industrial accidents, such as occurred in 1985 in Bhopal, India, and in 1976 in Seveso, near Milan, people in the neighbourhood of chemical plants were acutely exposed to lethal concentrations of these or other chemicals. The custom of transporting dangerous chemicals by rail or road has led to the occasional exposure of bystanders to toxic concentrations of gases and fumes. Although in many cases recovery may be complete, it seems clear that long-term damage may occur.
Disability and Attribution of Occupational Lung Diseases
Occupational lung diseases are of social and legal importance. In such cases, respiratory specialists must assess the extent of an individual’s disability and then form an opinion on whether an individual’s disability can be attributed to an occupational hazard. Pulmonary function testing and tests of exercise capability provide a good indication of the impact of a disease on the physical ability of a patient. However, it is much more difficult to decide how much of a patient’s disability is attributable to occupational exposure. If the exposure is historically known to cause a specific lesion in a significant percentage of exposed persons, such as mesothelioma in workers exposed to asbestos, attribution may be fairly straightforward. In many cases, however, the exposure may cause only generalized pulmonary changes or lung lesions for which the precise cause cannot be determined. These instances may be complicated by a history of cigarette smoking. Physicians asked to present opinions on attributability before a legal body frequently must rely on the application of probability statistics to the individual case, a not wholly satisfactory procedure.
toxic gases. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. When severe. Early mobilization after surgery or childbirth is considered an important preventive measure. these changes are known as a pulmonary infarction. Over time. and occasionally some pleuritic pain over the site of the infarction. environmental pollutants.
The lung is commonly involved in disorders of the circulation. This occurs most often during a postoperative period when the affected individual is immobilized in bed. The causative factors of these conditions may include accidents. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. The consequences of embolism range from sudden death. to an increased respiratory rate. in which the pressure in the main pulmonary artery is persistently increased. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. which occurs during mountain climbing and diving. ranging from poor pulmonary circulation to carbon monoxide poisoning.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
other respiratory conditions
Other respiratory conditions. which has usually formed in the veins of the legs or of the pelvis. and metabolic disorders. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. In addition. slight fever. comprise a diverse group of diseases and disorders. when the infarction is massive. a clot is replaced with
. conditions arising from exposure to extremes in atmospheric pressure.
ultimately. Prostacyclin can sometimes be given in oral or inhaled forms. The obstructing lesions can be surgically removed in some instances. a condition of unknown origin. and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart.7
The Respiratory System
an adherent fibrous material in the pulmonary arteries. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. affected individuals require careful. long-term evaluation and treatment. In addition to chest X-rays and basic pulmonary function tests. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. follows left ventricular failure. a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. right ventricular heart failure. usually after increasing disability with severe shortness of breath. causing shortness of breath on exertion and. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. usually as a consequence of coronary arterial disease. with consequent shortness of breath. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. In some cases. In primary pulmonary hypertension. lung transplantation is necessary. While some medications such as calcium channel blockers may be taken orally. When the
. thereby relieving symptoms of breathlessness.
The syndrome was formerly the leading cause of death in premature infants. which does the work of the lungs by oxygenating the
. Before the advent of effective treatment. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. cyanosis (a bluish tinge to the skin or mucous membranes). and abnormally low levels of oxygen in the arterial blood. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. 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. respiratory distress syndrome of infants was frequently fatal. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. The disorder arises because of a lack of surfactant.
Respiratory Distress Syndrome
Respiratory distress syndrome is a condition that can affect infants or adults.5 kg. 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.5 pounds). particularly those born to diabetic mothers. Although respiratory distress syndrome occurs mostly in premature. This complication is especially common in premature newborns. or approximately 5. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. it also sometimes develops in full-term infants.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
valve between the left atrium of the heart and the left ventricle is thickened and deformed by rheumatic fever (mitral stenosis). low-birth-weight infants (those weighing less than 2.
The Respiratory System
blood and removing carbon dioxide.000 people during that week and the subsequent three weeks. Life-support treatment with assisted ventilation rescues many patients. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. Acute respiratory distress syndrome carries about a 50 percent mortality rate.
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. Recovery and repair of the lung may take months after clinical recovery from the acute event. of the victims already had chronic heart or lung disease. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. exposure of the lung to gases. In adults. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. widespread bilateral lung injury. although superimposed infection or multiple organ failure can result in death. but not all. Many causes of respiratory distress syndrome of adults have been identified. Many. Most children who survive have no aftereffects. 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. bacterial or viral pneumonia. aspiration of material into the lung (including water in near-drowning episodes). which had been intermittently considered since the 14th century
. This syndrome is known as acute respiratory distress syndrome of adults. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. This episode spurred renewed attention to this problem.
respiratory tract infections in the young and old.com/Jupiterimages 181
.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
in England. This form of pollution. leads to the formation of photochemical smog. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories. is associated with excess mortality and increased prevalences of chronic bronchitis. This begins with the emission
Air pollution begins as emissions from sources such as industrial smokestacks. together with the bright sunlight and frequently stagnant air. and possibly lung cancer. the factor most responsible for the pollution. The large number of automobiles in that city. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities. Photos. and finally the passage of legislation banning open coal burning. common in many cities using coal as heating fuel. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles.
chest irritation with cough. In developed countries. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. The indoor environment can be important in the genesis of respiratory disease. These levels are commonly exceeded in many places. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. followed by the formation of nitrogen dioxide by oxygenation.
. Bangkok. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. Ozone is the most irritant gas known. and finally. and São Paulo. Eye irritation. through a complex series of reactions in the presence of hydrocarbons and sunlight. including Mexico City. Such exposures are common in the lives of millions of people. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. and repeated exposures may lead to lung cancer. and the impact of these exposures is an area of intense scientific investigation. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. and possibly the exacerbation of asthma occur as a result. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. which begins as emissions of nitrogen oxides. In developing countries.12 part per million.7
The Respiratory System
of nitrogen oxide during the morning commuting hour.
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. including combustion of gas in automobile engines. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
Carbon Monoxide Poisoning
Carbon monoxide poisoning is a common and dangerous hazard. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). Judgment is also impaired. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. the subject feels dizzy and is unable to perform simple tasks. Carbon monoxide is produced by incomplete combustion. leaving only 60 percent available to bind to oxygen). Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. 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. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. For this reason.
. as part of his detailed analysis of atmospheres in underground mines. a condition in which hemoglobin is deficient.
congestive heart failure. pulmonary embolism. which may be caused by anxiety. During hyperventilation the rate of
. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. or bicarbonate gain. This may be caused by severe acute or chronic lung disease. Alkalosis may be either metabolic or respiratory in origin. such as pneumonia or emphysema. shock. or pneumonia. 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. or by certain medications that suppress respiration in excessive doses. among others. Causes of metabolic acidosis include uncontrolled diabetes mellitus. asthma. Metabolic alkalosis results from either acid loss. in the body fluids.7
The Respiratory System
Acidosis is an abnormally high level of acidity. including the blood. including the blood.
Alkalosis and Hyperventilation
Alkalosis is an abnormally low level of acidity. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). Respiratory alkalosis results from hyperventilation. or high level of alkalinity. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. or low level of alkalinity. and renal failure. in the body fluids. such as general anesthetic agents. Hyperventilation is defined as a sustained abnormal increase in breathing. certain drugs or poisons.
causing symptoms such as shortness of breath. Inc. accumulation of fluid in the alveolar spaces can interfere with gas exchange.7
Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. Encyclopædia Britannica. Imbalances in the exchange of these gases can lead to dangerous respiratory disorders. In addition.
. such as respiratory acidosis or hyperventilation.
The Respiratory System
removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, respiratory alkalosis ensues. In turn, alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, including light-headedness and tingling of the fingertips. Severe hyperventilation can cause transient loss of consciousness. Anxiety is the most common cause of hyperventilation. Panic disorder, a severe episodic form of anxiety, usually causes hyperventilation with resultant symptoms. Treatment of recurrent hyperventilation begins with a complete explanation by the patient of the condition and the symptoms it causes. Some people benefit from psychotherapy and medications to deal with the underlying anxiety.
Hypoxia is a condition of the body in which the tissues are starved of oxygen. In its extreme form, where oxygen is entirely absent, the condition is called anoxia. There are four types of hypoxia: (1) the hypoxemic type, in which the oxygen pressure in the blood going to the tissues is too low to saturate the hemoglobin; (2) the anemic type, in which the amount of functional hemoglobin is too small, and hence the capacity of the blood to carry oxygen is too low; (3) the stagnant type, in which the blood is or may be normal but the flow of blood to the tissues is reduced or unevenly distributed; and (4) the histotoxic type, in which the tissue cells are poisoned and are therefore unable to make proper use of oxygen. Diseases of the blood, the heart and circulation, and the lungs may all produce some form of hypoxia.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The hypoxemic type of hypoxia is due to one of two mechanisms: 1. a decrease in the amount of breathable oxygen—often encountered in pilots, mountain climbers, and people living at high altitudes— due to the reduced barometric pressure, or 2. cardiopulmonary failure in which the lungs are unable to efficiently transfer oxygen from the alveoli to the blood. In the case of anemic hypoxia, either the total amount of hemoglobin is too small to supply the body’s oxygen needs, as in anemia or after severe bleeding, or hemoglobin that is present is rendered nonfunctional. Examples of the latter case are carbon monoxide poisoning and methoglobinuria, in both of which the hemoglobin is so altered by toxic agents that it becomes unavailable for oxygen transport, and thus of no respiratory value. Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock. Local stagnant hypoxia may be due to any condition that reduces or prevents the circulation of the blood in any area of the body. Examples include Raynaud disease and Buerger disease, which restrict circulation in the extremities; the application of a tourniquet to control bleeding; ergot poisoning; exposure to cold; and overwhelming systemic infection with shock. In histotoxic hypoxia the cells of the body are unable to use the oxygen, although the amount in the blood may be normal and under normal tension. Although
The Respiratory System
characteristically produced by cyanide, any agent that decreases cellular respiration may cause it. Some of these agents are narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents.
Altitude sickness, sometimes called mountain sickness, is an acute reaction to a change from sea level or other lowaltitude environments to altitudes above 2,400 metres (8,000 feet). Altitude sickness was recognized as early as the 16th century. In 1878 French physiologist Paul Bert demonstrated that the symptoms of altitude sickness are the result of a deficiency of oxygen in the tissues of the body. Mountain climbers, pilots, and persons living at high altitudes are the most likely to be affected. The symptoms of acute altitude sickness fall into four main categories: 1. respiratory symptoms such as shortness of breath upon exertion, and deeper and more rapid breathing; 2. mental or muscular symptoms such as weakness, fatigue, dizziness, lassitude, headache, sleeplessness, decreased mental acuity, decreased muscular coordination, and impaired sight and hearing; 3. cardiac symptoms such as pain in the chest, palpitations, and irregular heartbeat; and 4. gastrointestinal symptoms such as nausea and vomiting. The symptoms usually occur within six hours to four days after arrival at high altitude and disappear within two to five days as acclimatization occurs. Although most
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
people gradually recover as they adapt to the low atmospheric pressure of high altitude, some persons experience a reaction that can be severe and, unless they return to low altitude, possibly fatal. At higher altitudes, the air becomes thinner and the amount of breathable oxygen decreases. The lower barometric pressures of high altitudes lead to a lower partial pressure of oxygen in the alveoli, or air sacs in the lungs, which in turn decreases the amount of oxygen absorbed from the alveoli by red blood cells for transport to the body’s tissues. The resulting insufficiency of oxygen in the arterial blood supply causes the characteristic symptoms of altitude sickness. The main protection against altitude sickness in aircraft is the use of pressurized air in cabins. Mountain climbers often use a mixture of pure oxygen and air to relieve altitude sickness while climbing high mountains. In addition, the prophylactic use of the diuretic acetazolamide initiated two to three days before ascent may prevent or mitigate acute altitude sickness. A more serious type of altitude sickness, high altitude pulmonary edema (HAPE), occurs rarely among newcomers to altitude but more often affects those who have already become acclimated to high elevations and are returning after several days at sea level. In pulmonary edema, fluid accumulates in the lungs and prevents the victim from obtaining sufficient oxygen. The symptoms are quickly reversed when oxygen is given and the individual is evacuated to a lower area.
Barotrauma and Decompression Sickness
Barotrauma is any of several injuries arising from changes in pressure upon the body. Humans are adapted to live at an atmospheric pressure of 760 mm of mercury (the pressure at sea level), which differs from pressures experienced
small amounts of the gases that are present in the air. such as the ears. For example. in solution. sudden expansion of air trapped within the thorax can burst one or both lungs. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. In certain cavities of the body. A fatal form of barotrauma can occur in submariners and divers. When a pilot ascends to a higher altitude. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. At atmospheric pressure the body tissues contain.7
The Respiratory System
in underwater environments and in the upper atmospheres of space. face. and intestines. underwater divers. and these dissolved gases come
. however. 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. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. the external pressures upon his or her body decrease. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). sinuses. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). Pilots of unpressurized aircraft. lungs. or under the skin of the neck. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. the pleural spaces. and torso. there are air pockets that either expand or contract in response to changes in pressure. In decompression sickness (also called “the bends” or caisson disease) the formation of gas bubbles in the body because of rapid transition from a high-pressure environment to one of lower pressure causes a variety of physiological effects. such as the eardrum.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
out of solution. The gases then pass to the respiratory tract and are exhaled from the body. numbness. spinal cord. as the affected person commonly is unable to straighten joints. If the ascent is slow enough. Shallow. and personality changes. rapid respiration. When bubbles accumulate in the joints. Therefore. the gases have time to diffuse from the tissues into the bloodstream. The nervous system is composed of about 60 percent lipids. the “chokes. Bubbles forming in the brain. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). When the pressure decreases. speech defects. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. nausea. pain is usually severe and mobility is restricted. 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. often associated with a sharp retrosternal pain on deep inspiration. signals the onset of pulmonary decompression sickness. Nitrogen is much more soluble in fatty tissue than in other types. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. the excess nitrogen is released. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s
. Conversely.” The major component of air that causes decompression maladies is nitrogen. The term bends is derived from this affliction. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled.
or lung squeeze. is a type of barotrauma involving compression of the lungs and thoracic cavity. and the size of the lungs decreases. If compression continues. the air inside the lungs is compressed. Excessive coughing and difficulty in breathing. indicate nitrogen bubbles in the respiratory system. an increase in pressure causes air spaces and gas pockets within the body to compress. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. known as the chokes.
Thoracic squeeze. It most commonly occurs during a breath-holding dive underwater. the lung shrinks to about one-fourth its size at the surface. Too much air causes rupture of lung tissue. but this process is not always able to reverse damage to tissues. 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). Usually these symptoms pass in 10 to 20 minutes.
. If one descends to a depth of about 30 metres (100 feet). The outer linings of the lungs (pleural sacs) may separate from the chest wall. During the descent. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. and severe shock. while too little air causes compression and collapse of the lung walls. a burning sensation while breathing.7
The Respiratory System
itches. Other symptoms include chest pain. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. and the lung may collapse. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. Because the lung tissue is elastic and interspersed with tubules and sacs of air.
the diver may have difficulty in breathing. their lungs. It is now known that victims immersed for an hour or longer may be totally salvageable. The sperm whale is reported to dive to about 1.
Drowning is suffocation by immersion in a liquid. may exhale frothy blood. physically and intellectually. If the thoracic squeeze has been sufficient to cause lung damage. but eventually it ceases. Artificial respiration may be necessary if the breathing has stopped. even when reduced.300 feet). usually water. which can be relieved by ascending. 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. although they lack evidence of life. more than 10 times the depth that humans can tolerate. Any symptoms of thoracic squeeze call for prompt medical attention. Deprived of oxygen the victim stops struggling. and gives up the remaining tidal air in his or her lungs.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The predominant symptom felt by the diver is pain when the pressure becomes too great. or breathing—at the time of rescue. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen.000 metres (3. having no measurable vital signs—heartbeat. pulse. Until recently. and may even become unconscious. and their bodies are adapted to use the gases in the bloodstream more conservatively. 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. A fuller appreciation of the
. loses consciousness. do not separate from the chest wall. There the heart may continue to beat feebly for a brief interval. These aquatic mammals have been found to have more elastic chest cavities than humans.
In this suspended state. Up to 15 percent of drownings are “dry. Even though the heart functions at a slower rate.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. The mechanism is powerful in children. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. so that many people who once would have been given up for dead are being saved. Scientists have determined that vestiges of the reflex persist in humans.
. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. A natural biological mechanism that is triggered by contact with extremely cold water. enhances survival during submersion. abdomen. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. in other respects it performs normally. When aspiration does occur. thus permitting seagoing mammals to hunt for long periods underwater. actual aspiration of water into the lungs may or may not occur.7
The Respiratory System
body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. despite a total absence of respiratory gas exchange. and surface areas of the body to the heart and the brain. Often. known as the mammalian diving reflex. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. the volume of fluid entering the lungs rarely exceeds a glassful. It diverts blood from the limbs.
” “Lifeless” immersion victims with core temperatures as low as 62. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain.
. None of these effects is imminently life-threatening. 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). slows the heart rate.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
In warm water the body’s need for oxygen is increased. survival following hypothermic coma is almost 75 percent. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. and promotes unconsciousness. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia.6 °F (17 °C) have survived. Such warmwater drownings occur commonly in domestic bathtubs.
Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. This expansion of scientific understanding has enabled important progress in respiratory medicine. In addition. A cough productive of sputum is the most important manifestation of inflammatory or
. or respiratory medicine. many technological advances. and pathology of the human respiratory system is known as pulmonology. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. physiology. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. Likewise. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function.
recognizing the signs and syMptoMs of disease
The symptoms of lung disease are relatively few.CHAPTER7
APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT
he study of the anatomy. have contributed to improvements in the diagnosis and evaluation of respiratory disease. One of the most important advances in the history of respiratory medicine was the development of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. especially in the area of disease prevention. Today. particularly concerning techniques employing X-ray imaging or endoscopy.
it is constantly present. or shortness of breath. or walking uphill. resulting from occupational lung disease or arising from no identifiable antecedent condition.7
Approaches to Respiratory Evaluation and Treatment
malignant diseases of the major airways. particularly in the first two hours after awakening in the morning. may arise acutely. of complex origin. and. or with the onset of a severe attack of asthma. if the right ventricle that pumps blood through the lungs is functioning normally. It may become so severe as to immobilize the victim. Severe fibrosis of the lung. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. The second most important symptom of lung disease is dyspnea. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. such as walking up a flight of stairs. When this occurs. More often. of which bronchitis is a common example. and fluid may accumulate in
. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. as when a foreign body is inhaled into the trachea. playing golf. it may also indicate the presence of inflammation. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. the lung capillaries become engorged. or a tumour. in which there is irreversible lung damage. capillary damage. and tasks such as dressing cannot be performed without difficulty. commonly. This sensation. it is insidious in onset and slowly progressive. may also cause severe and unremitting dyspnea. The shortness of breath may vary in severity. Although it may result simply from an exacerbation of an existing infection. What is noted is a slowly progressive difficulty in completing some task. but in diseases such as emphysema. Hemoptysis is also a classic sign of tuberculosis of the lungs. 30 to 60 ml of sputum are produced in a 24-hour period.
The Respiratory System
small alveoli and airways. such as occurs in asthma. which leads to acute congestion of the affected part. This is caused by narrowing of the airways. rarely. 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). Chest pain may be an early symptom of lung disease. pain of this severity is rare. To these major symptoms of lung disease—coughing. a small lung cancer that is not obstructing an airway does not produce shortness of breath. severe chest pain may be caused by the spread of malignant disease to involve the pleura. A wheeziness in the chest may be heard. 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. but absence of the symptom does not mean that serious lung disease is not present. but it is most often associated with an attack of pneumonia. since. Severe. for example. diffuse
. Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. The pain disappears when fluid accumulates in the pleural space. dyspnea. and chest pain—may be added several others. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. Some diseases of the lung are associated with the swelling of the fingertips (and. pulmonary embolism. Acute pleurisy with pain may signal a blockage in a pulmonary vessel. a condition known as a pleural effusion. of the toes) called “clubbing. or by a tumour that arises from the pleura itself. such as a mesothelioma. can cause pleurisy. Fortunately. For example. In addition.
and lung cancer. are variable and nonspecific. for example. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints. may be diverse indicators of lung disease. such as mild indigestion or headaches. especially in the early stage. may be conscious of only a general feeling of malaise. cerebral signs from intracranial metastases. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. unusual fatigue.
Methods of inVestigation
Physical examination of the chest remains important. The generally debilitating effect of many lung diseases is well recognized. Because the symptoms of lung disease. the patient may feel as one does when convalescent after an attack of influenza. or seemingly minor symptoms as the first indication of disease. since a peripheral neuropathy may also be the presenting evidence of these tumours. as may sensory changes in the legs. this unusual sign may disappear after surgical removal of the tumour. In some lung diseases. Not infrequently. the first symptom may be a swelling of the lymph nodes that drain the affected area. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. A person with active lung tuberculosis or with lung cancer. Loss of appetite and loss of weight. Not infrequently. particularly the small nodes above the collarbone in the neck. In the case of lung cancer.7 Approaches to Respiratory Evaluation and Treatment
fibrosis of the lung from any cause. Thus. as it may reveal the presence of an area of inflammation. a
. a hip fracture from bone metastases. a disinclination for physical activity. and some symptoms apparently unrelated to the lung. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. general psychological depression.
or the pleural space. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment.7
The Respiratory System
pleural effusion. the lung tissue. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds. and the perfusion scan allows visualization of the blood vessels in the lungs. 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. tender areas. Methods of examination include physical inspection and palpation for masses. in the case of perfusion scanning. sputum examination for malignant cells is occasionally helpful. In these techniques. The sounds detected with a stethoscope may reveal abnormalities of the airways. or an airway obstruction. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). percussion to gauge the resonance of the underlying lung. because the technique is not well suited to imaging air-filled spaces. or injected. a radioactive tracer molecule is either inhaled. and abnormal breathing patterns. While the resolution of computerized tomography is much better than most other visualization techniques. The ventilation scan allows visualization of gas exchange in the bronchi and trachea. in the case of ventilation scanning. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. MRI is useful for imaging the heart and blood vessels within the
. and major bronchi. which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). By feeding a surgical instrument through a special channel of the bronchoscope. the distribution of ventilation within the lung. Tests of exercise capability. and after exercise. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. airflow resistance. Spirometry. the stiffness of the lung. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. which is often used in field studies. are useful in assessing functional impairment and disability. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units.7 Approaches to Respiratory Evaluation and Treatment
thorax. More complex laboratory equipment is necessary to measure the volumes of gas in the lung. trachea. and the rate of gas transfer across the lung. or the pressure required to inflate it. and gas exchange are compared before. in which workload. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. total ventilation. during. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function. Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. Ventilatory capability can be measured with a peak flow meter. physicians can collect fluid and small tissue samples from the airways.
7 The Respiratory System
A spirometry test measures lung capacity and degree of airflow obstruction. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs). and (2) those measuring respiratory function. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. Tests of ventilatory function include the following measurements: residual
. 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.
forced expiratory volume (FEV). maximal air volume expelled in 12 to 15 seconds of forced breathing. air volume within the chest in full inspiration. functional residual capacity (FRC). which measure the capacity of the lungs to move air in and out. or capillaries. vital capacity. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. and total lung capacity (TLC). tidal volume. and maximal expiratory flow rate (MEFR). This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. or air within the chest at the end of a quiet expiration. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. include maximal voluntary ventilation (MVV). Except for the residual volume. which is measured by a dilution method. 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. maximum air volume that can be expelled after a maximum inspiration. One of the most common screening roentgenograms is the chest film. maximal flow rate of a single expelled breath. Ventilation tests.
X-ray imaging is a valuable diagnostic technique used in medicine. breathing movements may also be registered graphically on a spirogram. taken to look for infections such as
. all the other volumes may be recorded with a spirometer. of the lungs. the resting lung volume. expressed in litres of air per minute. volume of a breath. maximum air volume expelled in a time interval.7 Approaches to Respiratory Evaluation and Treatment
volume (RV). who discovered X-rays in 1895. air remaining within the chest after a maximal expiration.
For the perfusion part of the scan. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs.7
The Respiratory System
tuberculosis and conditions such as heart disease and lung cancer. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. this technique is of little value in screening for lung cancer because the stage at which the disease is detectable by this method is too far advanced for treatment to be of value. or VQ (ventilation quotient) scan. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. thereby narrowing the passageway and hindering the flow of blood.
Lung Ventilation/Perfusion Scan
A lung ventilation/perfusion scan. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled
. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. unfortunately. A scanner that contains a radiation-sensitive camera is then used to collect images of the gamma rays emitted from the tracer as it circulates through the lungs. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. the blockage of one of the pulmonary arteries or of a connecting vessel. To track the movement of air. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. but. Pulmonary embolism is caused by a clot or an air bubble that has become lodged within a vessel or by the accumulation of fat along the inner walls of the vessel. This approach may be taken for patients with advanced or rapidly spreading lung cancer.
highlight places within the lungs where air or blood have accumulated abnormally. In both ventilation and perfusion scans.7 Approaches to Respiratory Evaluation and Treatment
with technetium). In contrast. including angiography.or blooddeprived. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. Although the tracers used in lung ventilation/perfusion scanning are radioactive. normal air and blood flow are reflected in the even distribution of tracers within the lungs. the tissues affected will be either oxygen. Thus. In general. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan. The appearance of hot spots. and another set of images is taken with the scanner. the ventilation and perfusion scans match for a person with healthy lungs. he or she may subsequently undergo more invasive procedures. the levels of radioactivity are exceptionally low and pose a very small risk to patients. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. Nutrient deprivation renders the tissue highly susceptible to death. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent
. a mismatch between the two scans is indicative of disease. or areas where the tracers become highly concentrated and therefore produce bright areas in the images.
Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope.
. Encyclopædia Britannica.7 The Respiratory System
The trachea and major bronchi of the human lungs. Inc.
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. In addition.
. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways. and to assist in the placement of stents (tubes. The second type of scope. to deliver certain therapeutic agents directly into the lungs. both flexible and rigid scopes have a channel through which instruments can be passed.g. There are two types of bronchoscopes. Flexible scopes. blood) to be removed during an examination.7 Approaches to Respiratory Evaluation and Treatment
cough or who are coughing up blood. because of their ability to bend and twist. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. Bronchoscopy is also employed to remove foreign objects from the airways. known as a rigid bronchoscope.. consists of a metal tube that has a wide suction channel. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. which enables large volumes of fluid (e. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. The most frequently used scope consists of a flexible tube containing a bundle of thin fibre-optic rods that project light onto the tissues being examined. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. they remain superior for specific applications.
causing them to bleed. as well as a set of lymph nodes. Bleeding is especially common following biopsy. upon waking. In most cases. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. and thymus gland. bleeding subsides without the need for medical intervention. In addition. there are several important risks associated with the bronchoscopy procedure itself. esophagus. trachea. because of the discomfort caused by the device. rigid bronchoscopy. necessitates the use of general anesthesia. In contrast. which can cause side effects in some people. serving as one of the primary
. including nausea and vomiting. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity.7
The Respiratory System
Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs.
Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. causing a condition known as pneumothorax. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. which occurs when the instrument is not sanitized properly. For example. Because the region of the mediastinum contains the heart. however. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. the movement of a bronchoscope through the airways often scratches superficial tissues.
light-emitting.7 Approaches to Respiratory Evaluation and Treatment
methods by which tissue samples are collected from the mediastinal lymph nodes for the staging of lung cancer. By carefully maneuvering the scope in the space. 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. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. including computerized axial tomography and positron emission tomography. Most patients recover within several days following mediastinoscopy. In cancer staging. This step of the procedure is known as mediastinotomy. The biopsy samples are then investigated for evidence of abnormalities.
. the doctor is able to investigate the surfaces of the various structures. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). which is performed under general anesthesia. Staging involves the investigation of cells to assess the degree to which cancer has spread. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. infection. Severe complications— such as bleeding. flexible instrument—is then passed through the incision and into the space between the lungs. a surgeon first makes a small incision in the patient’s neck. particularly for cellular defects associated with cancer and for the presence of infectious organisms. immediately above the sternum. During mediastinoscopy. and the procedure is associated with a very low risk of complications. such as abnormal growths or inflammation. A mediastinoscope—a thin. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope.
and maintenance of mechanical ventilators. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. produces vibrations that help to loosen and mobilize secretions. There are different methods of treatment employed in respiratory therapy. as in treatment of cystic fibrosis.7
The Respiratory System
types of respiratory therapy
Respiratory therapy is primarily concerned with assisting or improving the respiratory function of individuals with acute or chronic lung disease. mucolytics. each of which may be tailored to a specific disease. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. Medications. and antibiotics. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. A mixture of helium and oxygen is used to treat some diseases of airway obstruction. Therapy may involve the administration of gases for inhalation. Chest percussion. One of the conditions frequently dealt with is obstruction of breathing passages. hot steam. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. performed manually or by means of a handheld percussor or vest. Aerosol humidifiers called nebulizers may be powered by compressor machinery or by a hand-squeezed bulb to project medication or water spray into the airway. In addition. such as bronchodilators. adjustment. Oxygen may be administered in controlled amounts to assist laboured breathing.
. or a fog (as in an oxygen tent or a croup tent). respiratory therapists are experts in the setup.
and antibiotics. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. decongestants and antihistamines are available over the counter. decongestants. That is. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. antihistamines. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. veins. and thus they are used by many people. that are of particular importance in the routine treatment of respiratory illness. When administered in nasal sprays or drops or in devices for inhalation. they mimic the effects of stimulation of the sympathetic
. However. thus reducing blood flow to the inflamed areas. The relative safety and efficacy of these drugs has made them generally reliable medications. 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. the arterioles. due to the emergence of resistant organisms. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. and larger arteries respond to some degree. although capillaries. The constricting action chiefly affects the smallest arteries. In countries such as the United States. there are three groups.7 Approaches to Respiratory Evaluation and Treatment
There are many different types of drugs that may be used in the treatment of respiratory diseases.
headache. Because none of them has a sustained effect. One of the chief drugs of the group is epinephrine. however. dizziness. They include phenylephrine hydrochloride. results in absorption into the bloodstream. an alkaloid originally obtained from the leaves of ma huang. in which epinephrine constricts the blood vessels of the skin. or heart palpitations. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. too frequent use. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of
. and allergy.000 years. thereby preventing histaminetriggered reactions under such conditions as stress. which has been used in Chinese medicine for more than 5. following its release from certain large cells (mast cells) within the body.7
The Respiratory System
division of the autonomic nervous system. they must be used repeatedly. inflammation. Ephedrine and other decongestants are made by chemical synthesis. amphetamine and several derivatives. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. insomnia. any of several species of shrubs of the genus Ephedra. and naphazoline hydrochloride. causing anxiety. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. The oldest and most important decongestant is ephedrine. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues.
it is unlikely that he or she will benefit from them. Antihistamines are not usually beneficial in treating the common cold and asthma. The development of these antihistamines dates from about 1937. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. edema. If a patient’s condition does not improve after three days of treatment with antihistamines. compounds that were more potent. Persons with urticaria. nearly all antihistamines produce undesirable side effects. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. Antihistamines are readily absorbed from the alimentary tract. tested later and found to be more potent. subsequently. Nasal irritation and watery discharge are most readily relieved. and less toxic were prepared. more specific. Anilinetype compounds. and certain sensitivity reactions respond well. In 1942. were too toxic for clinical use. itching. Other side effects include gastrointestinal irritation. antihistamines can control certain allergic conditions. blurred vision. Used in sufficiently large doses. and most are rendered inactive by monoamine oxidase enzymes in the liver. headache. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. and dryness of the mouth.7 Approaches to Respiratory Evaluation and Treatment
histamine except those on gastric secretion. The first antihistamines were derivatives of ethylamine. The most common side effect in adults is drowsiness. More than 100 antihistaminic compounds soon became available for treating patients.
. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. among them hay fever and seasonal rhinitis.
Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. at a high enough concentration to be effective (but not cause side effects). These drugs are usually administered orally.
The medical administration of oxygen is an important means of treating respiratory disease. are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin.g. cimetidine (Tagamet) was introduced. such as the tetracyclines. Compounds of this class suppress histamine-induced gastric secretion and have proved extremely useful in treating gastric and duodenal ulcers.. Antibiotics vary in their range of action. and they are especially important in the treatment of bacterial respiratory infections. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. act against a broad spectrum of different bacteria. and for a sufficient length of time to ensure that the infection is totally eradicated.7
The Respiratory System
During the 1970s an H2-blocking agent. Macrolides. azithromycin) are particularly effective in the treatment of bacterial respiratory infections. Some are highly specific. erythromycin. which inhibit bacterial protein synthesis. They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). but they can be given parenterally. clarithromycin. in which tissues such as the
. the bacillus responsible for diphtheria. whereas others. Antibiotics known as macrolides (e. Oxygen therapy is used for acute conditions.
oxygen may be administered by citizen responders via mouth-to-mouth breaths in cardiopulmonary resuscitation (CPR) or by emergency medical personnel via a face mask placed over the victim’s mouth and nose that is attached to a small. In both the hospital and the home settings.7 Approaches to Respiratory Evaluation and Treatment
brain and heart are at risk of oxygen deprivation. 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. which is inserted directly into the trachea by way of a hole made surgically in the neck. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). because the procedure can potentially stimulate the generation of DNA-damaging free radicals. 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.
. such as chronic obstructive pulmonary disease (COPD). a device inserted into the nostrils that is connected by tubing to an oxygen system. These applications are controversial. oxygen may be delivered through a face mask or through a nasal cannula. Some patients may require oxygen administration via a transtracheal catheter. known as hyperbaric oxygen therapy (HBOT). home oxygen therapy may be prescribed by a physician. Another form of therapy. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. In addition. however. HBOT has been promoted as an alternative therapy for certain conditions. portable compressed-gas oxygen cylinder. In emergency situations. For patients affected by chronic lung diseases.
provide a method of storing oxygen at concentrations greater than that occurring in ambient air. When it is released under pressure from cold storage. which maintain oxygen under high pressure and require the use of a regulator to modulate the flow of gas from the cylinder to the patient. In the ABG test. 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. and carbon dioxide levels are measured. a probe. oxygen. Stationary and portable oxygen concentrators have been developed for use in the home. Oxygen concentrators. Large stationary and small portable gas cylinders can be used in the hospital or the home. which draw in surrounding air and filter out nitrogen. blood is drawn from an artery.7
The Respiratory System
There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. Oxygen is usually administered in controlled amounts per minute. it is converted to a gas. as opposed to releasing gas constantly. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood
. which can be refilled at pharmacies or by delivery services. Two tests that are commonly used to assess the concentration of oxygen in the blood include the arterial blood gas (ABG) test and the pulse oximetry test. Oxygen turns to liquid only when it is kept at very cold temperatures. Another form of oxygen storage is in compressed-gas cylinders. generally placed over the end of a finger. In pulse oximetry. Oxygen also can be stored as a highly concentrated liquid. and blood acidity. a measure known as the flow rate. Flow rate is determined based on measurements of a patient’s blood oxygen levels. Liquid oxygen can be stored in small or large insulated containers. The stored oxygen can then be used by the patient when needed and is readily replenished. which necessitates more-frequent cylinder replacement.
such as with the drug bleomycin. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. leading to the damage of healthy tissues. For example. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. a chronic disorder affecting infants. Compressed-gas cylinders present a significant safety hazard in the home as well. Also. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD.7 Approaches to Respiratory Evaluation and Treatment
that are carrying oxygen. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. which can lead to tissue dysfunction and cell death. Bronchopulmonary dysplasia. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. if they are not secured and stored
. Excess oxygen flow also can result in conditions such as barotrauma. For example. If oxygen flow rate is too low. Likewise. oxygen therapy does not alter the progression of lung disease. In general. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. However. HBOT is associated with an increased risk of barotrauma of the ear. it does not appeal to some patients. adverse physiological effects may ensue if the flow rate is too high. a response that is amplified in the presence of excess oxygen.
The person using mouth-to-mouth breathing places the victim on his back. which has been found to be more effective than the manual methods used in the past. choking. and electric shock. suffocation. carbon monoxide poisoning. throat. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. can prevent some deaths from drowning. lifts the lower jaw forward and upward to open the air passage. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. Furthermore. strangulation. or other sources of ignition. oxygen can readily spread fire. they may cause explosions. Likewise. Such techniques. clears his mouth of foreign material and mucus. establishing and maintaining an open air passage from the upper respiratory tract (mouth.
. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing.7
The Respiratory System
properly. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. candles. if applied quickly and properly. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1.
Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. and pharynx) to the lungs and 2.
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.7 Approaches to Respiratory Evaluation and Treatment
Mouth-to-mouth breathing is the most effective means of manual artificial respiration.
Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion. a needle is inserted through the chest wall and into the effusion site in the pleural space.7
The Respiratory System
and clamps the nostrils. the abnormal accumulation of fluid in the pleural space. For diagnostic applications. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. particles such
. as well as to prevent further complications associated with the condition. the rescuer may cover both the victim’s mouth and nose. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs. including infectious organisms. permitting the victim to exhale.
Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. He then alternately breathes into the victim’s mouth and lifts his own mouth away. and lung infections. such as chest X-rays or computerized axial tomography chest scans. It is most often used to diagnose the cause of pleural effusion. including the lungs. liver. Prior to thoracentesis. including heart failure. The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. If the victim is a child. including pleural empyema. and spleen. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. such as tuberculosis and pneumonia. Once the needle is inserted. the results of chest percussion and imaging tests. In the subsequent thoracentesis procedure. tumours.
gas embolism. coagulopathy). In its simplest form. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks. However. Pressures
. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. carbon monoxide poisoning. which occurs when a needle punctures the lungs. The results of these analyses frequently warrant further diagnostic testing. gas gangrene resulting from infection by anaerobic bacteria. Experimental compression chambers first came into use around 1860. for several hours afterward patients are often observed for the manifestation of adverse effects. the accumulation of air in the pleural space.7 Approaches to Respiratory Evaluation and Treatment
as asbestos.. Minor complications associated with thoracentesis include pain and cough. More serious complications include pneumothorax. which are suggestive of mesothelioma or lung cancer. and aberrant stimulation of the vasovagal reaction. Thoracentesis is a relatively quick procedure. Thoracentesis is contraindicated in persons with bleeding disorders (i. particularly upon detection of cancerous cells. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate.e. Air. 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. and wounds that are difficult to heal. tissue injury arising from radiation therapy for cancer.
A hyperbaric chamber. leading to a drop in blood pressure and fainting (syncope). also known as a decompression chamber (or recompression chamber). and tumour cells. generally lasting about 10 to 15 minutes. another breathing mixture.
or from a combination of the two. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). which increases oxygen availability to the body in therapeutic treatment. In the treatment of carbon monoxide poisoning. Chris McGrath/ Getty Images
used for medical treatment are usually 1. for example. a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues.5 to 3 times higher than ordinary atmospheric pressure. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. In the treatment of decompression sickness.7 The Respiratory System
A hyperbaric chamber creates a high-pressure environment. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues.
but from the late 1970s bilateral lung transplantation had some striking results. pulmonary fibrosis. With proper selection of donor organs and proper transplantation technique.7 Approaches to Respiratory Evaluation and Treatment
Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. many people who die of severe head injuries.
In the 21st century. who may be relatively young. the techniques are being pursued aggressively in specialized centres. sarcoidosis. often have also suffered lung injury or lung infection. respiratory medicine has continued to fulfill a vital role in advancing scientists’ understanding of respiratory disease and of the basic cellular and molecular processes that contribute to the normal function of the
. Persons severely disabled by cystic fibrosis. which presumably would leave the lungs intact. Because transplantation offers the only hope for persons with severe lung disease. for example. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. Availability of donor lungs is sharply limited by the number of suitable donors. 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. survival at one year has been reported at 90 percent.
The negative influence of behaviours such as tobacco smoking on lung function is now well documented. However. with health and environmental concerns at the forefront. Such progress promises to reduce the global mortality of lung cancer. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. in 2009 researchers reported having mapped the genetic codes of rhinoviruses. acquiring genetic mutations that alter their infectious characteristics. In many countries. In fact. and similar preventable respiratory afflictions. For decades. basic knowledge of the viruses that cause the common cold eluded scientists. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. Influenza viruses circulate globally. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. which are the most frequent cause of the common cold. and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. mesothelioma. sometimes drastically increasing their ability to infect and cause disease in humans.7
The Respiratory System
respiratory system. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. The 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.
For example. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease.7 Approaches to Respiratory Evaluation and Treatment
Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease. In addition. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests.
. as well as new treatments. 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. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. As researchers and physicians continue to uncover new information about the human respiratory system.
epiglottis Cartilaginous. Also known as a decompression chamber or recompression chamber. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. moving it upward or downward. during the act of swallowing. or transformation of glucose into energy. hypercapnia Excess carbon dioxide retention. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. glycolysis Fermentation. hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. glottis A sagittal slit formed by the vocal cords. leaf-shaped flap. functions as a lid to the larynx and. controls the traffic of air and food.GLOSSARY
apnea Cessation of breathing. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum.
. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. Act on the larynx as a whole. convection The transfer of heat by movement of a heated fluid such as air or water.
and tension of the vocal cords. length. a thin membranous sac encasing each lung. when added to a liquid. metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. purulent Pus-producing. pleura In humans. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx. resulting in the development of secondary tumours. and as the organ of phonation. paranasal sinuses Cavities in the bones that adjoin the nose. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. thereby increasing its spreading and wetting properties. neuraminidase A glycoprotein on the surface of influenza viruses.
. rhinitis Inflammation of the mucous tissue of the nose. surfactant Substance that. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses.7 Glossary
hypoxia Reduction of oxygen supply to tissues to less than physiological levels. reduces its surface tension. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself.
The Physiology and Medicine of Diving. Control of Breathing in Health and Disease (1999). 4 vol.). Berger.). (1994). H.). Physiology of Respiration. Pack (eds. (1988).. Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. The effects of swimming and diving on respiration are detailed in Peter B. Fraser et al. Peter T. Bates. 2nd. a detailed text on impairment of lung function caused by disease. HighAltitude Medicine and Pathology. Abnormal breathing during sleep is covered by Nicholas A. ed. (1993). (2001). 1 also available in a 3rd ed. Altose and Yoshikazu Kawakami (eds. Fishman and Jack A. The human respiratory system is described in David V. Murray. Sleep and Breathing. 2nd ed. Sullivan (eds. Control of breathing is described in Murray D. (1977–79). Christie. and Michael P. 2nd ed. Corwin Hinshaw and John F. Saunders and Colin E. with vol. 4th ed. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. 2nd ed. Dempsey and Allan I. (1995). Fishman’s Pulmonary Diseases and Disorders. and Ronald V. Macklem.. 2nd ed. Hlastala and Albert J.). Elias. Regulation of Breathing. and Robert G. (1971). Diagnosis of Diseases of the Chest. 4th ed. The Respiratory System (2003). (2008). Bennett and David H. and Jerome A. (1995).
. 4th ed. Elliott (eds.BIBLIOGRAPHY
Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores.
is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. (1981). Bateman. John Crofton and Andrew Douglas.).7 Bibliography
Diseases of the Chest. Alfred P. Weinberger. (2005). Textbook of Respiratory Medicine. Disorders of the Respiratory System. provides a comprehensive overview of pathophysiology as related to clinical syndromes. (1988). (1998). 2nd ed. See also John F. (1980). G.). see also J. is a general textbook covering diagnosis and treatment of chest diseases. 4th ed. Murray and Jay A. 2nd ed.. Pulmonary Diseases and Disorders. 3rd ed. 3rd ed. Respiratory Diseases. and Andrew M. Scadding and Gordon Cumming (eds. Steven E. (1994). (1980). Scientific Foundations of Respiratory Medicine (1981). 3 vol. 2nd ed. Fishman (ed. Churg et al. 3rd ed. Respiratory Disorders (1983).).). Cameron and Nigel T.
. Thurlbeck’s Pathology of the Lung. Nadel (eds. and Ian R. Comprehensive texts include Gordon Cumming and Stephen J. Semple. (eds. Principles of Pulmonary Medicine.
99–100. 124–125. 193 anthracosis. 171–173 asphyxiation. 117. 136. Jules. 46. 74. 188–189 alveoli. structure of. Georgius. 194 asthma.
. 209 animals. 169. 152. 175. 92. 184. 75 acidosis. structure and function of. 171 antibiotics. 52. 141–144
barotrauma. 129. 134. 153. 137. 188 bird fancier’s lung. 168–169. 160–164. 111. 187 byssinosis. 214 antihistamines. 30. 174–175
cancer. 94. 93. 174 Buerger disease. 42. 48 apnea. 212–214 aortic body. 50 Breuer. Paul. 152. structure and function of. 108. 171–173. 218–220 asbestos. 127. 35. 171. 102. 169. 169.INDEX
acid–base balance. 33–34 stem. 33–34 bronchiolitis. 175. 210. 75. 173. 111 Adam’s apple. 123. 91. structure of. 107. 196. 205–208 brown lung. 85 artificial respiration. 76. 73. 217 bronchoscopy. 122. 171 AIDS. 187 anesthesia. 223 bronchitis. 100–102. 126 arterial gas embolism. 110. 116. 115. 168. 28–29 bronchiectasis. 198 bronchioles. 159. 152–156. 81. 184 Actinomyces. 86. 217 Bert. 111. 147. 106 bradykinin.130–131. 176. 109. 169 lung. 30. 172. 197. 170–171 Bordet. 131–133. 182. 181. 30. 189–192. 186. Josef. 118–119 air–blood barrier. 131. 38. 34–35 amantadine. 49 bronchi. 39 alcoholism. 208. 51. 211. 97. 112–113. 79–80. 81. 114. 213 atelectasis. 221 asbestosis. 135. 159. 137. 103 anemia. 27 adenosine triphosphate (ATP). 96. 64. 166 black lung. 164. 197 bronchopulmonary dysplasia. 127. 103. 198. 52. 46. 184–186 altitude sickness. 211. 77 Agricola. 113 alkalosis.
201. 69–72 Gengou. 151
decompression sickness. 95. 21. 65. 197. 186. 191–193 drowning. 50. 85. abnormal. 69. Ewald. 60. 25. 137. 44. 183. 46. 156–158. 67 chronic obstructive pulmonary disease (COPD). 105–106. 188–189. 106. 30 Goodpasture syndrome. 174. 159. 65. 111. 81. 147. 157–158. 74 goblet cells. 150 epiglottis. 207 physiology of. 220. 79–81. 98–99 epiglottitis. 192. 145–148. 67. 171. John Scott. 78. 161. 34 cold. 84. 197–198
Haldane. 93. 211–212 diaphragm. 122. 145. 51–52. 190 histamine. 130. 164. 183. 177. 222 decongestants. 52 Cheyne-Stokes breathing. 212 exercise (training). 223
emphysema. 95. 30. 66. 215. 52 chloride shift. 137. 198. 213 hemoglobin. 102. 199. 75. 170. 216–217 Hering. 183 hay fever. 48. 184. 204. 196–197. 27. 143. 135. 64. 187. 221 cardiopulmonary resuscitation (CPR). Octave. 182
gas exchange. 158 diffusion limitation. 81 central nervous system disease. 218 dyspnea. 72 diphtheria. 98. 197. 223 eosinophilic granuloma. 47. 166 fungi. 50. 63. 190.7 Index 181. 122. 106 glycolysis. 87. 81–86. 210. 80. 164 coughing blood. 158. 201
farmer’s lung. 112. 168. 215. 214 diving. 80. 187. 196. 119
. 160 HIV. 144. 25. 84. 98–99 epinephrine. 49 high altitudes. 149. 96. 189–192. 129. 97. 78. 175. common. 136–138. 98. 213 cause of. 132 types of. 91. 88–91. 130. 136. 49 Hering-Breuer reflex. 215 carotid body. 131. 193–195. 221. 137. 190. 62. 56. 130. 47. 127–129. 87. 75–78. 182. 86. 50. 58–59. 94. 88 corticosteroids. 115. 106. 94. 209. 47. 92. 64. 217 Clara cells. 108. 211. 156. 122. 132. 180. 117. 159. 98–99 cystic fibrosis. 98. 133–136. 198 croup. 138.
47. 44. 171–173. 93. 143. 76 Monge disease. 159 congestion of. 113–114. 31. 69. 208–209 mediastinum. 26. 87. 87. 127. 173
cancer of. 150. 178. 94 nerves laryngeal. 197 development of. 49. 76–77. 182. 78 anaerobic. 26–28 Legionnaire disease. 50 meningitis. 73–78. 117 mesothelioma. 209. 41. 129. 74. 81 mountain sickness. 156–158. 127. 128. 144–145. 204. 152–156. 177 size of. 95–96 larynx. 114. 163 hydrothorax. 172. 38–40 infarction. 88. 149 influenza. 138–141. 98. 37. structure and function of. 204–205
measles. 81–82. 83 hypersensitivity pneumonitis. 221 metabolism. 184
Laënnec. 122. 217 hypoxia. 38. 166–167 hyperventilation. 127 hygiene. 199. 91. 198. 119 hyperbaric chamber. 221–222 hypercapnia. 221 collapse of. 147. 199 bird flu. 103 H1N1. 149. 104 vaccine. 139. 70. 55–56. 26
The Respiratory System
hookworm. 151. 81 aerobic. 149. 110. 173. 92. 99 mediastinoscopy. 138. 114–115. 110. 46–48. 145
kidney. 196 laryngitis. 184–186 hypothyroidism. 176. 96. 74. 223 lung ventilation/perfusion scan. 68. 135–136. 215. 173. 100 lungs
nephritis. 125 hypoventilation. 214 leukemia. 50. 51–52. 126 hypoxemia. 94. René-ThéophileHyacinthe. 198. 186–188
idiopathic pulmonary fibrosis. 169. 102–105. 103. 31 transplantation of. 83. 81 mucoviscidosis. 99. 138. 215. 181. 45. 117. 52. 190. 167. 141. 178. 208 medulla.
131. 220 pneumothorax. structure and function of. 209. 127. 122 function of. 170. 104–105 respiratory distress syndrome. 108–113. 107 penicillin. 91. 47 vagus. 198. 164 pharyngitis. 69–71 silicosis. 198 pneumoconiosis. 92. 214 pertussis. 24–25 pickwickian syndrome. 118 prostaglandins. 155. 103. 137 oxygen therapy. 198 pleural effusion. 95. 91. 114 Pott disease. 92. 170 pneumonia. 93. 159. 19. 107. 141. 184. 85 nose cilia. 172. 45. 211. 93 sinusitis. 127.
sarcoidosis. 179–180 Reynaud disease. 127–129. 92–94. 128
Relenza. 33. 84. 130. 38. 56. 107–108. 139. 208.Wilhelm Conrad. 110 pulmonary alveolar proteinosis. 107. 203
parasites. 87. 180–182 pons. 198. 108. 91. 126. 44 Pontiac fever. 106. 126. 85. 108. 91–92. 146. 138. 220 pleurisy. 154. 52–53. 200. 50. 95 shunting. 57. 117. 168–169. 103. 211. 124. 88. 89 structure and function of. 126–130. 179 rheumatoid arthritis. 128. 214–218
128. 114. 105–106. 21–24. 41. 149–150. 113. 164 inflammation of. 34 pyothorax. 160 sleep. 23–24 sinus. 22. 169–170 sinuses. 31–32. 126 oseltamivir. 126 pleura. 214. 125. 99
obesity. 194 pulmonary parenchyma. 173. 152. 150–151 pulmonary edema. 122. 136.7 olfactory. 26. 214 pharynx. 22 irrigation of. 189. 94. 53. 136
. 180. 50 nitrogen narcosis. 36. 88 rimantadine. 104 osteoporosis. 103 Röntgen. 178. 129–130. 103. 93 congestion of. 111 parrot fever. 87. 208. 187 rheumatic fever. 137. 100 rhinoviruses. 87. 223 scarlet fever. 167. 33. 139. 221 pollution. 50 psittacosis.
103. 92. 123. 108. 138. 97
trachea. 164 snoring. 97. 107. 93. 102. 182. 53. 164. 96–98 trench mouth. false. 87. 220 typhoid. 58 ventilation–blood flow imbalance. 99. 172. 209 swimming. 128. 93. 214 surgery. 94–95. 171. 28–30 tracheitis. 119.7
The Respiratory System
smallpox. 87. 97. structure and function of. 33. 96. 88. 192–193 tonsillitis. 78. 171. 114–121. 95. 94 staphylococci. 25. 53. 104–105
. 99. 208. 110. 197. 21. 152. 92. 92. 150. 138. 103. 146 strep throat. 178. 116. 118. 105–107
zanamivir. 97. 220–221 thoracic emphyema. 133–135. 125. 106 thoracentesis. 92 streptococcal bacteria. 97. 163. 23–24. 69 vestibular folds. 95 tuberculosis. 199. 104 tetanus. 106. 27–28 vitamin C. 130. 96. 95. 164. 97 smell. 199. 129. 122. 136. 111. 138. 183. 170. 109. 91 vocal chords. 91. 143. 87. 94–95 tonsils. 204. 153. 27–28
Tamiflu. 56. 95. 155–156. 124
whooping cough. 97
vaccination. 81–86 syphilis. 91. 137. 176. 218 sneezing. 173 Valsalva maneuver. 94. 131–132. 123–124 sore throat. 92. 130. 94 smoking.102. 127–129 thoracic squeeze. 92. 91. 103. 175. 122. 198.