Kara. Luebering: Senior Manager Marilyn L.E. Inc. 159. 122. 226. Encyclopædia Britannica. QP121. Rogers. 230: A healthy set of lungs is the powerhouse behind the respiratory system. I.” Includes bibliographical references and index.(The human body) “In association with Britannica Educational Publishing. ISBN 978-1-61530-147-8 (library binding) 1.2—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. -. Barton: Senior Coordinator. cm. Distributed exclusively by Rosen Educational Services. 41. Copyright © 2011 Encyclopædia Britannica. Media Acquisition Kara Rogers: Senior Editor. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer.istockphoto. All rights reserved. First Edition Britannica Educational Publishing Michael I. Levy: Executive Editor J. New York. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. 87. Biomedical Sciences Rosen Educational Services Heather M. 228. © www.com / nicoolay . 196. Editorial Technologies Lisa S. Respiratory organs—Popular works. Chip Somodevilla/Getty Images On pages 19.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. 60. Production Control Steven Bosco: Director.) in association with Rosen Educational Services. Inc. LLC 29 East 21st Street. All rights reserved. For a listing of additional Britannica Educational Publishing titles.istockphoto.R467 2011 612. call toll free (800) 237-9932. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. Inc. © www. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager. p. NY 10010. Britannica. Rosen Educational Services. and the Thistle logo are registered trademarks of Encyclopædia Britannica.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. LLC.

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


The Respiratory System


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

Lung Development
After early embryogenesis, during which the lung primordium is laid down, the developing human lung undergoes four consecutive stages of development, ending after birth. The names of the stages describe the actual morphology of the prospective airways. The pseudoglandular stage exists from 5 to 17 weeks; the canalicular stage, from 16 to 26 weeks; the saccular stage, from 24 to 38 weeks; and finally the alveolar stage, from 36 weeks of fetal age to about 1 ½ to 2 years after birth. The lung appears around the 26th day of intrauterine life as a ventral bud of the prospective esophagus. The bud separates distally from the gut, divides, and starts to grow into the surrounding mesenchyme. The epithelial components of the lung are thus derived from the gut (i.e., they


Anatomy and Function of the Human Respiratory System


are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.


The Respiratory System


The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.


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


control of breathing
Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. The respiratory rhythm and the length of each phase of respiration are set by reciprocal stimulatory and inhibitory interconnection of these brain-stem neurons. An important characteristic of the human respiratory system is its ability to adjust breathing patterns to changes in both the internal milieu and the external environment. Ventilation increases and decreases in proportion to

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The volume in these circumstances is known as the residual volume. such as pieces of glass. muscular contraction occurs only on inspiration. capable of increasing its output 25 times. During ordinary breathing. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. 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. The respiratory pump is versatile. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. expiration being accomplished “passively” by elastic recoil of the lung. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax.154 cubic inches) per minute in adults. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. Pressures 57 . The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. 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. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. At total relaxation of the muscles of inspiration and expiration. separated by a film of water.

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

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

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

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

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

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

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

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

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

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

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

g. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. venous blood enters the bloodstream without passing through functioning lung tissue. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. In shunting. 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. alveoli filled with fluid or inflammatory material). 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. A reduction in arterial blood oxygenation is seen with shunting.7 Gas Exchange and Respiratory Adaptation 7 gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. ventilation– blood flow imbalance. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. and limitations of diffusion. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. Because of the differences in oxygen and carbon dioxide transport. but the level of carbon dioxide in arterial blood is not elevated even 69 . Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and decreases the spread of the virus through the body. If taken within 30 hours of 104 . Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. and decreases the spread of the virus through the body. Oseltamivir can be given orally. increases the formation of viral aggregates. Inc. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U. Zanamivir is given by inhalation only. There is evidence that the most common subtype of influenza type A virus. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses.based pharmaceutical company Hoffman–La Roche. known as H1N1. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. The drug can also be used to prevent flu in adults and children who take the medication once daily for a period of at least 10 days. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. zanamivir decreases the release of virus from infected cells. has developed resistance to oseltamivir.7 The Respiratory System 7 dangerous subtypes.S. the drug decreases the release of virus from infected cells. Through the inhibition of neuraminidase. a glycoprotein on the surface of influenza viruses. increases the formation of viral aggregates.S. Oseltamivir is effective when administered within two days of symptom onset. Oseltamivir is marketed as Tamiflu by the U.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

121 . such as kanamycin.7 Infectious Diseases of the Respiratory System 7 Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. in part to prevent the development and spread of MDR TB. Aggressive treatment using five different drugs. 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. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. Instead of taking daily medication on their own. it has proved successful in controlling tuberculosis. In 1995. or capreomycin. MDR TB is treatable but is extremely difficult to cure. In addition. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. amikacin. 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. Although some patients consider DOT invasive. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT).

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

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

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

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

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

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

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

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

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

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

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

7 Diseases and Disorders of the Respiratory System


the prevention of superimposed infections, either by careful watching for early signs or by using prophylactic antibiotics. Adjusting the patient’s living and working environments to the largely irreversible condition is an essential factor in treatment.

Pulmonary Emphysema
This irreversible disease consists of destruction of alveolar walls. It occurs in two forms, centrilobular emphysema, in which the destruction begins at the centre of the lobule, and panlobular (or panacinar) emphysema, in which alveolar destruction occurs in all alveoli within the lobule simultaneously. In advanced cases of either type, this distinction can be difficult to make. Centrilobular emphysema is the form most commonly seen in cigarette smokers, and some observers believe it is confined to smokers. It is more common in the upper lobes of the lung (for unknown reasons). By the time the disease has developed, some impairment of ventilatory ability has probably occurred. Panacinar emphysema may also occur in smokers, but it is the type of emphysema characteristically found in the lower lobes of patients with a deficiency in the antiproteolytic enzyme known as alpha-1 antitrypsin. Similar to centrilobular emphysema, panacinar emphysema causes ventilatory limitation and eventually blood gas changes. Other types of emphysema, of less importance than the two major varieties, may develop along the dividing walls of the lung (septal emphysema) or in association with scars from other lesions. A major step forward in understanding the development of emphysema followed the identification, in Sweden, of families with an inherited deficiency of alpha-1 antitrypsin, an enzyme essential for lung integrity. Members of affected families who smoked cigarettes


The Respiratory System


Emphysema destroys the walls of the alveoli of the lungs, resulting in a loss of surface area available for the exchange of oxygen and carbon dioxide during breathing. This produces symptoms of shortness of breath, coughing, and wheezing. In severe emphysema, difficulty in breathing leads to decreased oxygen intake, which causes headaches and symptoms of impaired mental ability. Encyclopædia Britannica, Inc.

commonly developed panacinar emphysema in the lower lobes, unassociated with chronic bronchitis but leading to ventilatory impairment and disability. Intense investigation of this major clue led to the “protease-antiprotease” theory of emphysema. It is postulated that cigarette smoking either increases the concentration of protease enzymes released in the lung (probably from white blood cells) or impairs the lung’s defenses against these enzymes or both. Although many details of the essential biochemical steps at the cellular level remain to be clarified, this represents a major step forward in understanding a disease whose

7 Diseases and Disorders of the Respiratory System


genesis was once ascribed to overinflation of the lung (like overdistending a bicycle tire). Chronic bronchitis and emphysema are distinct processes. Both may follow cigarette smoking, however, and they commonly occur together, so determination of the extent of each during life is not easy. In general, significant emphysema is more likely if ventilatory impairment is constant, gas transfer in the lung (usually measured with carbon monoxide) is reduced, and the lung volumes are abnormal. Development of high-resolution computerized tomography has greatly improved the accuracy of detection of emphysema. Some people with emphysema suffer severe incapacity before age 60. Thus, emphysema is not a disease of the elderly only. An accurate diagnosis can be made from pulmonary function tests, careful radiological examination, and a detailed history. The physical examination of the chest reveals evidence of airflow obstruction and overinflation of the lung, but the extent of lung destruction cannot be reliably gauged from these signs, and therefore laboratory tests are required. The prime symptom of emphysema, which is always accompanied by a loss of elasticity of the lung, is shortness of breath, initially on exercise only, and associated with loss of normal ventilatory ability and increased obstruction to expiratory airflow. The expiratory airflow from a maximum inspiration is measured by the “forced expiratory volume in one second,” or FEV1, and is a predictor of survival of emphysema. Chronic hypoxemia (lowered oxygen tension) often occurs in severe emphysema and leads to the development of increased blood pressure in the pulmonary circulation, which in turn leads to failure of the right ventricle of the heart. The symptoms and signs of right ventricular failure include swelling of the ankles (edema) and engorgement of the neck veins. These are portents of advanced lung disease in this condition. The


The Respiratory System


hypoxemia may also lead to an increase in total hemoglobin content and in the number of circulating red blood cells, as well as to psychological depression, irritability, loss of appetite, and loss of weight. Thus, the advanced syndrome of chronic obstructive lung disease may cause such shortness of breath that the afflicted person has difficulty walking, talking, and dressing, as well as numerous other symptoms. The slight fall in ventilation that normally accompanies sleep may exacerbate the failure of lung function in chronic obstructive lung disease, leading to a further fall in arterial oxygen tension and an increase in pulmonary arterial pressure. Unusual forms of emphysema also occur. In one form the disease appears to be unilateral, involving one lung only and causing few symptoms. Unilateral emphysema is believed to result from a severe bronchiolitis in childhood that prevented normal maturation of the lung on that side. “Congenital lobar emphysema” of infants is usually a misnomer, since there is no alveolar destruction. It is most commonly caused by overinflation of a lung lobe due to developmental malformation of cartilage in the wall of the major bronchus. Such lobes may have to be surgically removed to relieve the condition. Bullous emphysema can occur in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung tissue. This disease most commonly occurs between ages 15 and 30 and usually is not recognized until a bullous air space leaks into the pleural space, causing a pneumothorax.

Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by the

Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. It is a common disease. which is replaced by holes characteristic of emphysema. and by a tendency for excessive mucus production in the airway. and each year about 30.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). Exacerbations are triggered by infection. which work against bacteria. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin.000 people in the United States die from COPD. which gives rise to symptoms of bronchitis. which 137 . antibiotics. Coughing up blood is not a feature of COPD and when present raises concern about a second. which causes increased lung volume and manifests as breathlessness. indicate a poor prognosis. and the burning of certain fuels in poorly ventilated areas. it is increasingly recognized that COPD has secondary associations. particularly lung cancer. Although primarily a lung disease. COPD is distinguished pathologically by the destruction of lung tissue. including muscle weakness and osteoporosis. Therefore. air pollution. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). particularly if severe enough to warrant hospital admission.000 people in the United Kingdom and roughly 119. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. Sources of noxious particles that can cause COPD include tobacco smoke. Frequent exacerbations. either bacterial or viral. are not always required. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. tobacco-related condition.

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

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

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

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

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

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

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

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

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

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

which subsequently incorporated the normal genes into their DNA. Gene therapy first emerged as a potential form of treatment in 1990. 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. However. the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. has proved particularly effective in laboratory studies using human lung tissue.7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. These vectors were then transfected into the cultured cells. gene therapy for cystic fibrosis has undergone significant refinement. 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. 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. Since the 1990s. However. The latter. This first trial initially appeared to be successful. 148 . The same technology was used to insert the CFTR gene into a replication-deficient adenovirus that was then administered into the noses and lungs of patients. As a result. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. since increased expression of the CFTR protein was observed shortly after treatment. including lung inflammation and signs of viral infection. which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. cationic liposomes. the patients experienced severe side effects.

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

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

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

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

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

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

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

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

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

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

For example. traumatic conditions. such as respiratory distress syndrome. altitude sickness. many of which are acute in nature. First. reducing exposure to the irritant relieves the symptoms of their condition. affected persons are highly sensitive to substances such as dust or pollen. such as asbestos and coal dust. exposure to harmful irritants. For most affected persons.CHAPTER6 ALLERGIC AND OCCUPATIONAL LUNG DISEASES AND ACUTE RESPIRATORY CONDITIONS llergic and occupational lung diseases comprise two groups of conditions that are associated with the exposure to and inhalation of particulate matter. leading to cancer and substantial loss of lung function. In the case of allergies. 159 . causes respiratory disease in otherwise healthy workers. and drowning are other examples of acute conditions that can result in respiratory failure. In occupational disease. and. the lungs are exposed to the outside environment. A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. decompression sickness. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. Respiratory function can be severely compromised by a variety of other conditions. hence. severe respiratory disease may ensue. however. Carbon monoxide poisoning. In some cases of occupational exposure.

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

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

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

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

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

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

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

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

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

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

and. however. and gas exchange is poor. and pneumonia. In the actual disease process. that serve to protect the body from bacterial invasion. and the abdominal lymph nodes. 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.000 particles of silica per cubic foot (about 210. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. The symptoms of silicosis are shortness of breath that is followed by coughing. though this has changed with the availability of drug therapies for that disease. and particles of one to three microns do the most damage. called macrophages. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6.0004 inch) in diameter penetrate to the finer air passages of the lungs. and weakness. Silicosis predisposes a person to tuberculosis. also known as coal-worker’s pneumoconiosis. difficulty in breathing. is a respiratory disorder caused by repeated inhalation of 170 . the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. cannot be digested by the macrophages and instead kill them. Silica particles. There is no cure for silicosis. In the past a large proportion of sufferers of silicosis died of tuberculosis. Lung volume is reduced. control of the disease lies mainly in prevention. Black Lung Black lung. Only very small silica particles less than 10 microns (0. the openings to the lungs. These whorls of fibrous tissue may spread to involve the area around the heart. emphysema. since there is no effective treatment.000 per litre) of air.000.

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

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

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.

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

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

The disorder arises because of a lack of surfactant. particularly those born to diabetic mothers. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 valve between the left atrium of the heart and the left ventricle is thickened and deformed by rheumatic fever (mitral stenosis).5 kg. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. cyanosis (a bluish tinge to the skin or mucous membranes). 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. These changes contribute to the shortness of breath and account for the blood staining of the sputum. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. In infants it is also called hyaline membrane disease. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. low-birth-weight infants (those weighing less than 2. 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 is characterized by extremely laboured breathing. which does the work of the lungs by oxygenating the 179 .5 pounds). it also sometimes develops in full-term infants. Before the advent of effective treatment. The syndrome was formerly the leading cause of death in premature infants. respiratory distress syndrome of infants was frequently fatal. and abnormally low levels of oxygen in the arterial blood.

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

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

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

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

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

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


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
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

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

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

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

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

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

and promotes unconsciousness. survival following hypothermic coma is almost 75 percent. None of these effects is imminently life-threatening. slows the heart rate.6 °F (17 °C) have survived. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. 195 . Such warmwater drownings occur commonly in domestic bathtubs.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. Immersion in icy water causes body temperature and metabolism to fall rapidly (the thermal conductivity of water is 32 times greater than that of air). Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia.” “Lifeless” immersion victims with core temperatures as low as 62.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

often have also suffered lung injury or lung infection. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. many people who die of severe head injuries. which presumably would leave the lungs intact. With proper selection of donor organs and proper transplantation technique. pulmonary fibrosis. the techniques are being pursued aggressively in specialized centres. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. for example. Persons severely disabled by cystic fibrosis. survival at one year has been reported at 90 percent. sarcoidosis. but from the late 1970s bilateral lung transplantation had some striking results. Because transplantation offers the only hope for persons with severe lung disease.7 Approaches to Respiratory Evaluation and Treatment 7 Lung Transplantation Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. 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. emphysema. Availability of donor lungs is sharply limited by the number of suitable donors. respiratory medicine has continued to fulfill a vital role in advancing scientists’ understanding of respiratory disease and of the basic cellular and molecular processes that contribute to the normal function of the 223 . who may be relatively young. conclusion In the 21st century.

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

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

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

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

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

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

152. 34–35 amantadine. 51. 169 lung. 197 bronchopulmonary dysplasia. structure of. 91. 114. 152–156. 111. 52. 49 bronchi. 135. 169. 76. Paul. 182. 75 acidosis. 102. 168–169. 197. 188 bird fancier’s lung. 160–164. 52. 137. 110. 159. 106 bradykinin. 209 animals. 92. 127. 171–173. 81. 38. 181. 194 asthma. 212–214 aortic body. 184–186 altitude sickness. 171–173 asphyxiation. 189–192. 171. 174 Buerger disease. 126 arterial gas embolism. 127. 208. 97. 217 bronchoscopy. Georgius. 170–171 Bordet. 75. 136. 64. 108.130–131. 205–208 brown lung. 129. 73. 184. 109. 48 apnea. 164. 175. 172. 137. 187 anesthesia. 131. 134. 193 anthracosis. 186. 115. 117. Josef. 35. 223 bronchitis. 33–34 bronchiolitis. 85 artificial respiration. 46. 184 Actinomyces. 28–29 bronchiectasis. Jules. 39 alcoholism. structure and function of. 124–125. 159. 74. 96. 152. 42. 81. 198. 168. 153. 111. 122. 116. 171 antibiotics. 198 bronchioles. 171 AIDS. 50 Breuer. 30. 196. 79–80. 173. structure of. 214 antihistamines. 176. 77 Agricola. 46. 30. 93. 211. 187 byssinosis. 103. 169. 211. 230 . 99–100. 175. 217 Bert. 174–175 C cancer. 30. 111 Adam’s apple. 188–189 alveoli. 113 alkalosis. 123.INDEX A acid–base balance. 33–34 stem. 213 atelectasis. 100–102. 147. 94. 169. 218–220 asbestos. 131–133. 118–119 air–blood barrier. 103 anemia. 27 adenosine triphosphate (ATP). 221 asbestosis. 86. 210. 112–113. 141–144 B barotrauma. 107. 166 black lung. structure and function of.

74 goblet cells. 197. 69–72 Gengou. 62. 175. 161. 207 physiology of. 189–192. 88–91. 222 decongestants. 133–136. 131. 217 Clara cells. 25. 193–195. 122. 67. 63. 137. 50. 94. 156–158. 65. 197–198 H Haldane. 204. 158. 69. 187. 184. 84. 127–129. 211–212 diaphragm. 215. 80. 47. 106 glycolysis. 96. 156. 159. 214 diving. 91. 201 F farmer’s lung. 149. 188–189. 174. 166 fungi. 88 corticosteroids. 150 epiglottis. 25. 105–106. 108. 177. Octave. 64. 27. 199. 115. 98–99 epinephrine. abnormal. 92. 81 central nervous system disease. 98–99 cystic fibrosis. 106. 196. 187. 112. 220. 137. 97. 132 types of. 98. 95. 64. 213 cause of. 130. 182 G gas exchange. 78. 168. 60. 210. 48. 117. 201. 50. 75–78. 72 diphtheria. 157–158. 183. 182.7 Index 181. 137. 151 D decompression sickness. 138. 47. 145–148. 216–217 Hering. 111. 198. 213 hemoglobin. 67 chronic obstructive pulmonary disease (COPD). 98. 132. 119 231 . 21. 46. 164. 130. Ewald. 186. 122. 102. 47. 81–86. 84. 143. 198 croup. 65. 52 chloride shift. 30 Goodpasture syndrome. 218 dyspnea. 49 high altitudes. 34 cold. 81. 66. 197. 58–59. 122. 191–193 drowning. 75. 159. 192. 190. 50. 147. 51–52. 56. 79–81. 160 HIV. 80. 164 coughing blood. 49 Hering-Breuer reflex. 98. 211. 170. 190. 130. 212 exercise (training). 215 carotid body. 144. 106. 180. 78. 223 eosinophilic granuloma. 98–99 epiglottitis. 86. 94. 190 histamine. 196–197. 30. 223 7 E emphysema. 215. 183. 171. 52 Cheyne-Stokes breathing. 87. John Scott. 221. 136. 158 diffusion limitation. common. 44. 135. 93. 95. 209. 183 hay fever. 85. 87. 145. 136–138. 129. 221 cardiopulmonary resuscitation (CPR).

215. 173. 94 nerves laryngeal. 217 hypoxia. 114–115. 196 laryngitis. 208–209 mediastinum. 98. 127 hygiene. 69. 127. 177 size of. 76 Monge disease. 149. 46–48. structure and function of. 114. 221 collapse of. 198. 51–52. 81–82. 186–188 I idiopathic pulmonary fibrosis. 92. 99. 181. 149. 113–114. 102–105. 172. 41. 38. 73–78. 208 medulla. 156–158. 128. 100 lungs N nephritis. 125 hypoventilation. 81 mucoviscidosis. 182. 159 congestion of. 83 hypersensitivity pneumonitis. 55–56. 44. 184–186 hypothyroidism. 126 hypoxemia. 199 bird flu. 96. 76–77. 103. 74. 166–167 hyperventilation. 221 metabolism. René-ThéophileHyacinthe. 173 cancer of. 221–222 hypercapnia. 163 hydrothorax. 45. 26–28 Legionnaire disease. 91. 171–173.7 The Respiratory System 7 hookworm. 26. 135–136. 49. 176. 88. 122. 178. 83. 223 lung ventilation/perfusion scan. 138. 167. 215. 143. 31. 117. 99 mediastinoscopy. 145 K kidney. 184 L Laënnec. 95–96 larynx. 74. 110. 52. 214 leukemia. 119 hyperbaric chamber. 50 meningitis. 197 development of. 31 transplantation of. 87. 138. 144–145. 199. 198. 117 mesothelioma. 81 mountain sickness. 37. 38–40 infarction. 103 H1N1. 94. 204. 209. 149 influenza. 104 vaccine. 78 anaerobic. 87. 127. 152–156. 50. 93. 129. 68. 110. 178. 147. 138–141. 151. 190. 26 232 . 81 aerobic. 70. 173. 204–205 M measles. 47. 141. 139. 169. 150.

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

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

Sign up to vote on this title
UsefulNot useful