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

CONTENTS Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels. Lymphatic Vessels. and 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 .

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

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

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

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

INTRODUCTION .

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

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

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

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

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

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

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

Treatment may also be based on the results of genetic screening. . As this book shows. the human respiratory system is a finely tuned feat of engineering. and radiation.7 The Respiratory System 7 Lung cancer treatments may consist of surgery. A healthy set of lungs is nothing to take for granted. 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. and the consequences of neglecting or damaging that fragile system can be drastic. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. chemotherapy.

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

Atmospheric air is pumped in and out regularly through a system of pipes. 20 . The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product. Inc. 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. Encyclopædia Britannica. called conducting airways.

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

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

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

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

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

Sound is produced by forcing air through a sagittal slit formed by the vocal cords. Control is achieved by a number of muscles innervated by the laryngeal nerves.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. the glottis. This portion of the chest membrane is called the parietal pleura. The chest cavity is lined with a serous membrane. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. most of them minute. The pleural cavity is the space. and as the organ of phonation. as the mediastinal pleura. the two surfaces tend to touch. between the parietal and the visceral pleura. the mediastinum being the space and the tissues and structures between the two lungs. the thyroid cartilage. is made of two plates fused 26 . where it is called the visceral pleura. The laryngeal skeleton consists of almost a dozen pieces of cartilage. this function can be closely controlled and finely tuned. 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. and over part of the esophagus. This causes not only the vocal cords but also the column of air above them to vibrate. the heart. when it occurs. As evidenced by trained singers. and the great vessels. the muscles must be anchored to a stabilizing framework. For the precise function of the muscular apparatus. The largest cartilage of the larynx. interconnected by ligaments and membranes. so called because it exudes a thin fluid. or serum. 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 cricoid. This mechanism plays an important role in altering length and tension of the vocal cords. Viewed frontally. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. they are also formed by the free end 27 . with its narrowest width at the glottis. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. resembling an organ pipe. They correspond to elastic ligaments attached anteriorly in the angle of the thyroid shield and posteriorly to a pair of small pyramidal pieces of cartilage. below it is a forward projection. the lumen of the laryngeal tube has an hourglass shape. another large cartilaginous piece of the laryngeal skeleton. the arytenoid cartilages. The vocal ligaments are part of a tube. has a signet-ring shape. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them.7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. At the upper end of the fusion line is an incision. they follow its tilting movement. the epiglottis is also attached to the back of the thyroid plate by its stalk. Behind the shieldlike thyroid cartilage. the vocal cords span the laryngeal lumen. Just above the vocal cords. made of elastic tissue. Because the arytenoid cartilages rest upright on the cricoid plate. The transverse axis of the joint allows a hingelike rotation between the two cartilages. which has given this structure the common name of Adam’s apple. to which it is joined in an articulation reinforced by ligaments. Both of these structures are easily felt through the skin. 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. Like the true vocal cords. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. The cricoid is located below the thyroid cartilage. the laryngeal prominence.

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

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

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

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

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

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

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

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

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

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

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The Respiratory System

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

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

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are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.
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The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.

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

T

control of breathing
Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. The respiratory rhythm and the length of each phase of respiration are set by reciprocal stimulatory and inhibitory interconnection of these brain-stem neurons. An important characteristic of the human respiratory system is its ability to adjust breathing patterns to changes in both the internal milieu and the external environment. Ventilation increases and decreases in proportion to
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Although the diaphragm is the major muscle of breathing. and muscles such as the scalene and sternocleidomastoid that attach both to the ribs and to the cervical spine at the base of the skull also play an important role in the exchange of air between the atmosphere and the lungs. In addition. such as speaking. such as the airway narrowing that occurs in an asthmatic attack. abdominal muscles. and maintaining posture. 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. breathing can be 42 . Intercostal muscles inserting on the ribs. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. and the extent of muscle shortening. These same muscles are used to perform a number of other functions. they also complicate the regulation of breathing.7 The Respiratory System 7 swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act. chewing and swallowing. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. the size of the airway. Mechanoreceptors monitor the expansion of the lung. the force of respiratory muscle contraction. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. laryngeal muscles and muscles in the oral and nasal pharynx adjust the resistance of movement of gases through the upper airways during both inspiration and expiration. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement.

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

which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. allowing the activity of these physiological systems to be coordinated with respiration. 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. 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. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. in turn they drive cranial motor neurons. Neurally. which supply the diaphragm and other thoracic and abdominal muscles. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors.

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

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

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

ventilation increases nearly linearly. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. which then act on the sensory nerve. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. and substance P. which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. Current thinking places these receptors near the undersurface (ventral part) of the 48 . The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. 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. are located within the vesicles. As the partial pressure of carbon dioxide in arterial blood rises. Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. 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. This observation shows that there must be additional receptors that respond to changes in the partial pressure of 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.7 The Respiratory System 7 intestinal peptide. Even if both the carotid and aortic bodies are removed. 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. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide.

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

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

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

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

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

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

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

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

muscular contraction occurs only on inspiration. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. The respiratory pump is versatile. At total relaxation of the muscles of inspiration and expiration.154 cubic inches) per minute in adults. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. separated by a film of water. During ordinary breathing. such as pieces of glass. expiration being accomplished “passively” by elastic recoil of the lung. capable of increasing its output 25 times. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. The volume in these circumstances is known as the residual volume. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). Pressures 57 .

© www .istockphoto. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver. The beating of cilia (hairline projections) from cells lining the airways 58 .7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx.e. 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..com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. Airflow velocity. with no space between the vocal cords).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. 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. Normal lungs. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. such adherence occasionally does occur and is one of the dreaded complications of premature births. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces. 59 . 500 millilitres. and seven litres. totaling about 0. 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. however.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. respectively. In fact.

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

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

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

Plasma. so less than 2 percent of oxygen is transported dissolved in plasma. transport of oxygen Oxygen is poorly soluble in plasma. Most oxygen is bound to hemoglobin. therefore. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. which make up 40 to 50 percent of the blood volume in most mammals. Enough hemoglobin is present in normal human blood to permit transport of about 0.2 ml of oxygen per ml of blood. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. important determinants of gas transport. Each iron atom can bind and then release an oxygen molecule. plays little role in oxygen exchange but is essential to carbon dioxide exchange. 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. called the oxygen-dissociation curve. The curve representing the content of oxygen in blood at various partial pressures of oxygen. liquid portion of blood. The amount of oxygen 63 . the cell-free. In alveoli at sea level. These systems are present mainly in the red cells. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed. a protein contained within red cells.

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

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

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

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

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

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. ventilation– blood flow imbalance. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. Because of the differences in oxygen and carbon dioxide transport. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. shunting. In 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. but the level of carbon dioxide in arterial blood is not elevated even 69 . A reduction in arterial blood oxygenation is seen with shunting. and limitations of diffusion..g. alveoli filled with fluid or inflammatory material). These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. 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. 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. Oxygen in excess can be a poison. which in a mixture with less than 4 percent oxygen is noncombustible. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. An ability to tolerate carbon dioxide may increase the work capacity of a diver at depth but also may predispose him to other consequences that are less desirable. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels. approximately in proportion to the reciprocal of the square root of the increasing gas density. High values of end-tidal carbon dioxide with 84 . like an anesthetic. has the additional advantage of providing a breathing gas of lesser density. provides a greater respiratory advantage for deep diving. At the extreme depths now attainable by humans— some 500 metres (1.7 The Respiratory System 7 increased. it may cause the rapid onset of convulsions.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. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. In mixed-gas diving.640 feet) in the sea and more than 680 metres (2. At a partial pressure greater than 1.2 and 0. The use of hydrogen.5 bar (“surface equivalent value” = 150 percent).5 bar.

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

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. which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure.6 feet).7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. 86 . Decompression sickness is caused by the formation of bubbles from gases that were dissolved in the tissues while the diver was at an increased environmental pressure. 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

commonly developed panacinar emphysema in the lower lobes, unassociated with chronic bronchitis but leading to ventilatory impairment and disability. Intense investigation of this major clue led to the “protease-antiprotease” theory of emphysema. It is postulated that cigarette smoking either increases the concentration of protease enzymes released in the lung (probably from white blood cells) or impairs the lung’s defenses against these enzymes or both. Although many details of the essential biochemical steps at the cellular level remain to be clarified, this represents a major step forward in understanding a disease whose
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genesis was once ascribed to overinflation of the lung (like overdistending a bicycle tire). Chronic bronchitis and emphysema are distinct processes. Both may follow cigarette smoking, however, and they commonly occur together, so determination of the extent of each during life is not easy. In general, significant emphysema is more likely if ventilatory impairment is constant, gas transfer in the lung (usually measured with carbon monoxide) is reduced, and the lung volumes are abnormal. Development of high-resolution computerized tomography has greatly improved the accuracy of detection of emphysema. Some people with emphysema suffer severe incapacity before age 60. Thus, emphysema is not a disease of the elderly only. An accurate diagnosis can be made from pulmonary function tests, careful radiological examination, and a detailed history. The physical examination of the chest reveals evidence of airflow obstruction and overinflation of the lung, but the extent of lung destruction cannot be reliably gauged from these signs, and therefore laboratory tests are required. The prime symptom of emphysema, which is always accompanied by a loss of elasticity of the lung, is shortness of breath, initially on exercise only, and associated with loss of normal ventilatory ability and increased obstruction to expiratory airflow. The expiratory airflow from a maximum inspiration is measured by the “forced expiratory volume in one second,” or FEV1, and is a predictor of survival of emphysema. Chronic hypoxemia (lowered oxygen tension) often occurs in severe emphysema and leads to the development of increased blood pressure in the pulmonary circulation, which in turn leads to failure of the right ventricle of the heart. The symptoms and signs of right ventricular failure include swelling of the ankles (edema) and engorgement of the neck veins. These are portents of advanced lung disease in this condition. The
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hypoxemia may also lead to an increase in total hemoglobin content and in the number of circulating red blood cells, as well as to psychological depression, irritability, loss of appetite, and loss of weight. Thus, the advanced syndrome of chronic obstructive lung disease may cause such shortness of breath that the afflicted person has difficulty walking, talking, and dressing, as well as numerous other symptoms. The slight fall in ventilation that normally accompanies sleep may exacerbate the failure of lung function in chronic obstructive lung disease, leading to a further fall in arterial oxygen tension and an increase in pulmonary arterial pressure. Unusual forms of emphysema also occur. In one form the disease appears to be unilateral, involving one lung only and causing few symptoms. Unilateral emphysema is believed to result from a severe bronchiolitis in childhood that prevented normal maturation of the lung on that side. “Congenital lobar emphysema” of infants is usually a misnomer, since there is no alveolar destruction. It is most commonly caused by overinflation of a lung lobe due to developmental malformation of cartilage in the wall of the major bronchus. Such lobes may have to be surgically removed to relieve the condition. Bullous emphysema can occur in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung tissue. This disease most commonly occurs between ages 15 and 30 and usually is not recognized until a bullous air space leaks into the pleural space, causing a pneumothorax.

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

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

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

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

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

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

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

fever. sticky mucus that clogs the respiratory tract and the gastrointestinal tract. It is much less common among people of African ancestry (about 1 per 17. Cystic fibrosis was not recognized as a separate disease until 1938 and was then classified as a childhood disease because mortality among afflicted infants and children was high. when both 145 . and a dull sound heard when the chest is tapped.000 live births) and is very rare in people of Asian ancestry. However. The dead tissue is replaced by scar tissue. Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. It is estimated to occur in 1 per 2.e. the chief symptom of which is the production of a thick.. coughing. Infarcts that do not heal within two or three days generally take two to three weeks to heal. those individuals who have one normal copy and one defective copy of the particular gene involved). The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). However. diminished breath sounds. also known as mucoviscidosis.000 live births in these populations and is particularly concentrated in people of northwestern European descent. by the mid-1980s. The disorder was long known to be recessive (i. pleural rubbing.e. The disease has no manifestations in heterozygotes (i. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. increased heartbeat. only persons inheriting a defective gene from both parents will manifest the disease). is an inherited metabolic disorder.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. Cystic Fibrosis Cystic fibrosis. moderate difficulty in breathing..

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

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

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

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

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

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

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

small-cell 153 . Types of Lung Cancer Once diagnosed. The risk is also greater for those who started smoking at a young age. and roofers. tar refiners. visible lumps. or bone pain may occur. such as coal processors. secondhand smoke accounts for an estimated 3.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. Heavy smokers have a greater likelihood of developing the disease than do light smokers. According to the American Cancer Society. bloody sputum. jaundice. Other risk factors include exposure to radon gas and asbestos. and susceptibility to lower respiratory infections. In countries with a prolonged history of cigarette smoking. Uranium and pitchblende miners. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. The most common symptoms include shortness of breath. Lung cancer is rarely caused directly by inherited mutations. chromium and nickel refiners. between 80 and 90 percent of all cases are caused by smoking. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. as do some workers in hydrocarbon-related processing. the tumour’s type and degree of invasiveness are determined. Of the two basic forms.400 deaths from lung cancer in nonsmoking adults in the United States each year. welders. and workers exposed to halogenated ethers also have an increased incidence. unexplained weight loss. a persistent cough or wheeze. In cases where the cancer has spread beyond the lungs. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. Tumours can begin anywhere in the lung. chest pain.

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

the five-year survival rate is about 50 percent. chemotherapy. which can identify mutations that render some lung cancers susceptible to specific drugs. and the type of cancer. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. positron emission tomography (PET) scans.7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. For example. The choice of treatment depends on the patient’s general health. Even when it is detected early. and radiation. As with most cancers. Lung surgery is serious and can lead to complications such as pneumonia or bleeding. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . 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. and magnetic resonance imaging (MRI). Surgery involves the removal of a cancerous segment (segmentectomy). For this reason. or the entire lung (pneumonectomy). treatments for lung cancer include surgery. a lobe of the lung (lobectomy). computed tomography (CT) scans. Noninvasive methods include X-rays. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. abnormal fluctuations in the serum levels of parathormone or the presence in the blood of a protein called cytokeratin 19 fragment or of substances known as carcinogenic antigens may be indicative of malignant lung disease. The type of treatment an individual patient receives may also be based on the results of genetic screening. lung cancer has a poorer prognosis than many other cancers.

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

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

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

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

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

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

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

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

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

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

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

7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Some species of the fungi genus Aspergillus can cause allergic reactions and mild pneumonia in susceptible individuals. or in response to a variety of other agents. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. but sometimes the precise agent cannot be identified. occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 . Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. 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.

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

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

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

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. which causes similar symptoms. The first disease recognized to be caused by asbestos was asbestosis. as coal dust often is contaminated with silica. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. however. brake linings. Georgius Agricola. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. There is strong evidence that tobacco smoking aggravates the condition. Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. led to a virtual epidemic of asbestos-related disease 20 years later. The disease is most commonly found among miners of hard coal. tuberculosis is also more common in victims of black lung. 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. and the extent of disease is clearly related to the total dust exposure. and as a fire protectant sprayed inside buildings. first described lung disease in coal miners in the 16th century. It is not clear. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. and it is now widely recognized. but it also occurs in soft-coal miners and graphite workers. Onset of the disease is gradual. It may be the best known occupational illness in the United States. a German mineralogist. ceiling tiles. and later in flooring. whether coal itself is solely responsible for the disease. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to 171 .

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

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

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

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beryllium alloys, and a slow-developing chronic disease occurring in scientific and industrial workers who are exposed to beryllium-containing fumes and dust. The acute disease involves both skin and lungs, causing a burning rash, eye irritation, nasal discharge, a cough, and chest tightness. The skin disease is caused by direct contact with beryllium salts and the lung disease by inhalation of metal dust or beryllium compounds. Most of those affected by acute berylliosis recover within a few months, but a small number of patients develop a highly fatal inflammation of the lung within 72 hours after a brief, massive exposure to beryllium. The chronic disease may occur more than 15 years after exposure, although the later it develops, the milder it is likely to be. It generally causes shortness of breath, especially after exercise, exhaustion, and a dry cough and can produce a permanent, though moderate, disability.

Byssinosis
Byssinosis, or brown lung, is a respiratory disorder caused by inhalation of an endotoxin produced by bacteria in the fibres of cotton, flax, hemp, and other textiles. Byssinosis is common among textile workers, who often inhale significant amounts of cotton dust. Cotton dust may stimulate inflammation that damages the normal structure of the lung and causes the release of histamine, which constricts the air passages. As a result, breathing becomes difficult. Over time the dust accumulates in the lung, producing a typical discoloration that gives the disease its common name. Byssinosis was first recognized in the 17th century and was widely known in Europe and England by the early 19th century. Today it is seen in most cotton-producing

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regions of the world. Several years of exposure to cotton dust are needed before byssinosis develops, and workers with lower grade disease usually recover completely upon leaving the industry or moving into an area with less dust. Persons with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure continues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Because cotton is by far the most common cause of byssinosis, this form of the condition has been variably known as cotton-dust asthma and cotton-mill fever.

Respiratory Toxicity of Industrial Chemicals
Toluene diisocyanate, used in the manufacture of polyurethane foam, may cause occupational asthma in susceptible individuals at very low concentrations. In higher concentrations, such as may occur with accidental spillage, it causes a transient flulike illness associated with airflow obstruction. Prompt recognition of this syndrome has led to modifications in the industrial process involved. Although the acute effects of exposure to many of these gases and vapours are well documented, there is less certainty about the long-term effects of repeated low-level exposures over a long period of time. This is particularly the case when the question of whether work in a generally dusty environment has contributed to the development of chronic bronchitis or later emphysema. In other words, whether such nonspecific exposures increase the risk of these diseases in cigarette smokers. Many chemicals can damage the lung in high concentration: these include oxides of nitrogen, ammonia,

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chlorine, oxides of sulfur, ozone, gasoline vapour, and benzene. In industrial accidents, such as occurred in 1985 in Bhopal, India, and in 1976 in Seveso, near Milan, people in the neighbourhood of chemical plants were acutely exposed to lethal concentrations of these or other chemicals. The custom of transporting dangerous chemicals by rail or road has led to the occasional exposure of bystanders to toxic concentrations of gases and fumes. Although in many cases recovery may be complete, it seems clear that long-term damage may occur.

Disability and Attribution of Occupational Lung Diseases
Occupational lung diseases are of social and legal importance. In such cases, respiratory specialists must assess the extent of an individual’s disability and then form an opinion on whether an individual’s disability can be attributed to an occupational hazard. Pulmonary function testing and tests of exercise capability provide a good indication of the impact of a disease on the physical ability of a patient. However, it is much more difficult to decide how much of a patient’s disability is attributable to occupational exposure. If the exposure is historically known to cause a specific lesion in a significant percentage of exposed persons, such as mesothelioma in workers exposed to asbestos, attribution may be fairly straightforward. In many cases, however, the exposure may cause only generalized pulmonary changes or lung lesions for which the precise cause cannot be determined. These instances may be complicated by a history of cigarette smoking. Physicians asked to present opinions on attributability before a legal body frequently must rely on the application of probability statistics to the individual case, a not wholly satisfactory procedure.
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In addition. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. in which the pressure in the main pulmonary artery is persistently increased. which occurs during mountain climbing and diving. comprise a diverse group of diseases and disorders. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. When severe. a clot is replaced with 177 . The consequences of embolism range from sudden death. This occurs most often during a postoperative period when the affected individual is immobilized in bed. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. toxic gases. ranging from poor pulmonary circulation to carbon monoxide poisoning. Circulatory Disorders The lung is commonly involved in disorders of the circulation. and occasionally some pleuritic pain over the site of the infarction. The causative factors of these conditions may include accidents. which has usually formed in the veins of the legs or of the pelvis. Early mobilization after surgery or childbirth is considered an important preventive measure. slight fever. when the infarction is massive. these changes are known as a pulmonary infarction. Over time. conditions arising from exposure to extremes in atmospheric pressure. and metabolic disorders. environmental pollutants. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. to an increased respiratory rate.

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

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

of the victims already had chronic heart or lung disease. This syndrome is known as acute respiratory distress syndrome of adults. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. Many. Most children who survive have no aftereffects. widespread bilateral lung injury. but not all. aspiration of material into the lung (including water in near-drowning episodes). although superimposed infection or multiple organ failure can result in death. Air Pollution The disastrous fog and attendant high levels of sulfur dioxide and particulate pollution (and probably also sulfuric acid) that occurred in London in the second week of December 1952 led to the deaths of more than 4.000 people during that week and the subsequent three weeks. Prize cattle at an agricultural show also died in the same period as a result of the air pollution. Life-support treatment with assisted ventilation rescues many patients. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden.7 The Respiratory System 7 blood and removing carbon dioxide. bacterial or viral pneumonia. exposure of the lung to gases. This episode spurred renewed attention to this problem. Recovery and repair of the lung may take months after clinical recovery from the acute event. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. which had been intermittently considered since the 14th century 180 . Many causes of respiratory distress syndrome of adults have been identified. Acute respiratory distress syndrome carries about a 50 percent mortality rate. As the infant’s lungs mature and begin to produce surfactant—usually within three to five days after birth—the child is weaned from the ventilator. In adults.

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

and repeated exposures may lead to lung cancer. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0.12 part per million. and São Paulo. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. which begins as emissions of nitrogen oxides. through a complex series of reactions in the presence of hydrocarbons and sunlight. chest irritation with cough. including Mexico City. and finally.7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. Ozone is the most irritant gas known. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. These levels are commonly exceeded in many places. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. In developing countries. Bangkok. followed by the formation of nitrogen dioxide by oxygenation. Eye irritation. and possibly the exacerbation of asthma occur as a result. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. 182 . The indoor environment can be important in the genesis of respiratory disease. and the impact of these exposures is an area of intense scientific investigation. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. In developed countries. Such exposures are common in the lives of millions of people. A tightly sealed house may act as a reservoir for radon seeping in from natural sources.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. 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 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 . or the transfer of gas between the alveoli and the blood.

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

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. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. unfortunately.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. thereby narrowing the passageway and hindering the flow of blood. This approach may be taken for patients with advanced or rapidly spreading lung cancer. the blockage of one of the pulmonary arteries or of a connecting vessel. but. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. For the perfusion part of the scan. Pulmonary embolism is caused by a clot or an air bubble that has become lodged within a vessel or by the accumulation of fat along the inner walls of the vessel. A scanner that contains a radiation-sensitive camera is then used to collect images of the gamma rays emitted from the tracer as it circulates through the lungs. Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. 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. or VQ (ventilation quotient) scan. To track the movement of air. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As researchers and physicians continue to uncover new information about the human respiratory system. For example. 225 . discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease.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. 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. In addition. as well as new treatments.

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

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

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

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

153. 169 lung. 152–156. 184 Actinomyces. 52. 169. 50 Breuer. 30. 193 anthracosis. 175. 99–100. 152. 174 Buerger disease. 184–186 altitude sickness. 30. 182. 196.INDEX A acid–base balance. 33–34 bronchiolitis. 122. 171–173 asphyxiation. 111. 96. 74. 106 bradykinin. 211. 118–119 air–blood barrier. 169. 46. 79–80. 218–220 asbestos. 75 acidosis. 46. 93. 110. structure and function of. 77 Agricola. 213 atelectasis. 42. 52. 34–35 amantadine. 187 anesthesia. 123. 111. 127. 49 bronchi. 173. 103 anemia. 103. 33–34 stem. 114. 127. 198. 111 Adam’s apple. 171–173. 217 Bert. 126 arterial gas embolism. 115. 136. 129. 171 AIDS. 92. 230 . 30. 160–164. structure of. 187 byssinosis. 188 bird fancier’s lung. Paul. 85 artificial respiration. 81. 212–214 aortic body. 113 alkalosis. 210. 217 bronchoscopy. 186. 174–175 C cancer. Georgius. 124–125. 108. 198 bronchioles. 221 asbestosis. 97. 109. 188–189 alveoli. 27 adenosine triphosphate (ATP). 159. 168. 51. 181. 131. 117. structure and function of. 134. 214 antihistamines. 102. 172. structure of. 64. 39 alcoholism. 205–208 brown lung. 73. 175. 164. Josef. 116. 197. 94.130–131. 100–102. 194 asthma. 168–169. 112–113. 152. 197 bronchopulmonary dysplasia. 91. 171. 211. Jules. 76. 75. 81. 86. 48 apnea. 209 animals. 189–192. 147. 184. 38. 169. 176. 223 bronchitis. 137. 131–133. 135. 171 antibiotics. 141–144 B barotrauma. 28–29 bronchiectasis. 166 black lung. 107. 137. 208. 35. 159. 170–171 Bordet.

197–198 H Haldane. 137. 215. 88–91. 52 Cheyne-Stokes breathing. 174. 95. 129. 201. 166 fungi. 204. 215. 48. 192. 198. 111. 170. 98–99 cystic fibrosis. 130. 190. 87. Ewald. 81 central nervous system disease. 183. 159. 130. 137. 210. 182. 25. 130. 159. 96. 161. 69–72 Gengou. 138. 122. 80. 183 hay fever. 106. 67 chronic obstructive pulmonary disease (COPD). 25. 151 D decompression sickness. 183. 180. 150 epiglottis. 98–99 epiglottitis. 212 exercise (training). 50. 160 HIV. 147. 64. 221. 94. 106 glycolysis. 177. 164. 63. 199. 122. 213 cause of. 196. 145–148. 149. 127–129. 223 eosinophilic granuloma. 222 decongestants. 119 231 . 44. 184. 132 types of. 27. 75. 175. 182 G gas exchange. 105–106. 46. 189–192. 201 F farmer’s lung. 191–193 drowning. 190 histamine. Octave. 218 dyspnea. 133–136. 47. 75–78. 93. 171. 209. 67. 207 physiology of. 221 cardiopulmonary resuscitation (CPR). 49 Hering-Breuer reflex. 145. 98. 65. 216–217 Hering. 84. 80. 213 hemoglobin. 217 Clara cells. common. 112. 91. 47. 21.7 Index 181. 115. 56. 131. 164 coughing blood. 211. 122. 78. 30. 50. 135. 62. 87. 143. 81–86. 156. 132. 51–52. 117. 220. 187. abnormal. 92. 95. 157–158. 186. 72 diphtheria. 136–138. 94. 102. 60. 84. 223 7 E emphysema. 97. 98–99 epinephrine. 64. 98. 98. 187. 52 chloride shift. 69. 49 high altitudes. 50. 158. 85. 168. 197. 88 corticosteroids. 74 goblet cells. John Scott. 106. 196–197. 188–189. 78. 30 Goodpasture syndrome. 198 croup. 86. 214 diving. 158 diffusion limitation. 211–212 diaphragm. 47. 81. 144. 197. 136. 58–59. 66. 79–81. 65. 193–195. 190. 34 cold. 137. 108. 156–158. 215 carotid body.

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

41. 170. 138. 114 Pott disease. 124. 149–150. 19. 91. 104 osteoporosis. 168–169. 137. 129–130. 89 structure and function of. 24–25 pickwickian syndrome. 47 vagus. 26. 56. 117. 139. 198 pneumoconiosis. 92–94. 126. 69–71 silicosis. 105–106. 93. 211. 169–170 sinuses. 108. 87. 198 pleural effusion. structure and function of. 208. 33. 128. 184. 103. 50 nitrogen narcosis. 154. 106. 180–182 pons. 85. 95 shunting. 179–180 Reynaud disease. 22 irrigation of. 167. 214. 103. 100 rhinoviruses. 107 penicillin. 87. 220 pneumothorax. 103 Röntgen. 53. 103. 57. S sarcoidosis. 110 pulmonary alveolar proteinosis. 139. 198. 93 sinusitis. 50 psittacosis. 118 prostaglandins. 122 function of. 150–151 pulmonary edema. 23–24 sinus.Wilhelm Conrad. 136 233 . 108. 160 sleep. 152. 126. 85 nose cilia. 94. 45. 127–129. 107. 88 rimantadine. 130. 88. 114. 221 pollution. 214 pharynx. 141. 170 pneumonia. 92. 93 congestion of. 92. 126 oseltamivir. 164 pharyngitis. 179 rheumatoid arthritis. 36. 34 pyothorax. 91–92. 164 inflammation of. 198. 91. 136.7 olfactory. 220 pleurisy. 159. 203 P parasites. 22. 113. 155. 99 Index 7 O obesity. 127. 107. 214 pertussis. 21–24. 95. 84. 50. 178. 223 scarlet fever. 128 R Relenza. 172. 126–130. 146. 126 pleura. 111 parrot fever. 44 Pontiac fever. 38. 194 pulmonary parenchyma. 137 oxygen therapy. 31–32. 87. 208. 187 rheumatic fever. 209. 125. 211. 200. 33. 104–105 respiratory distress syndrome. 189. 108–113. 180. 107–108. 52–53. 173. 127. 214–218 128. 131. 122. 91.

164. 192–193 tonsillitis. 97 smell. 199. 104 tetanus. 88. 103. 127–129 thoracic squeeze. 133–135. 94–95 tonsils. 33. 116. 146 strep throat. 138. 138. 97. 81–86 syphilis. 91 vocal chords. 96. 53. 92 streptococcal bacteria. 178. 87. 123–124 sore throat. 110. 108. 182. 96. 124 W whooping cough. 93. 103. 78. 143. 105–107 Z zanamivir. 91. 171. false. 111. 94. 129. 99. 97. 95. 97 V vaccination. 150. 69 vestibular folds. 91. 198. 87. 218 sneezing. 27–28 vitamin C. 53. 92. 152. 138. 214 surgery. 209 swimming. 103. 92. 128. 27–28 T Tamiflu. 220 typhoid. 99. 122. 106 thoracentesis. 163. 94 smoking. 173 Valsalva maneuver. 93. 107. 125. 153. 21. 164. 131–132. 106. 95 tuberculosis. 220–221 thoracic emphyema. 118. 183. 96–98 trench mouth. 25. 208. 94–95. 92. 95. 137. 199. 130. 97. 94 staphylococci. 175. 164 snoring. 123. 92. 176. 87. 28–30 tracheitis. 197. 170. 104–105 234 . 136. 130. 114–121. 119. 122. 58 ventilation–blood flow imbalance. 92. 97 trachea. 56. 109. 97. 102.102. 172. 95. 155–156. structure and function of. 204. 171. 23–24. 91.7 The Respiratory System 7 smallpox.