Copyright © 2011 Encyclopædia Britannica.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.(The human body) “In association with Britannica Educational Publishing. Inc. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. cm. Inc. call toll free (800) 237-9932. © www. NY 10010. 41. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. 226. 159. All rights reserved. Respiratory organs—Popular works. 228.istockphoto. 230: A healthy set of lungs is the powerhouse behind the respiratory system. 122. Rogers. Biomedical Sciences Rosen Educational Services Heather M. ISBN 978-1-61530-147-8 (library binding) 1. Chip Somodevilla/Getty Images On pages 19. QP121. -. Kara. Luebering: Senior Manager Marilyn L.com / nicoolay
. Barton: Senior Coordinator. All rights reserved.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. © www. LLC. and the Thistle logo are registered trademarks of Encyclopædia Britannica. Distributed exclusively by Rosen Educational Services. Inc. 196. p. New York. Levy: Executive Editor J.) in association with Rosen Educational Services. 60.” Includes bibliographical references and index. Production Control Steven Bosco: Director. First Edition Britannica Educational Publishing Michael I. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager.R467 2011 612. For a listing of additional Britannica Educational Publishing titles.E. LLC 29 East 21st Street. Media Acquisition Kara Rogers: Senior Editor. Encyclopædia Britannica. 87.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control.istockphoto. I. Britannica. Editorial Technologies Lisa S. Rosen Educational Services.
and Nerves 36 Lung Development 38 Chapter 2: Control and Mechanics of Breathing 41 Control of Breathing 41 Central Organization of Respiratory Neurons 44 Chemoreceptors 46 Peripheral Chemoreceptors 46 Central Chemoreceptors 48 Muscle and Lung Receptors 49 Variations in Breathing 50 Exercise 51 Sleep 52
Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels. Lymphatic Vessels.
and Metabolism 73 Adaptations 78 High Altitudes 79 Swimming and Diving 81 Chapter 4: Infectious Diseases of the Respiratory System 87 Upper Respiratory System Infections 88 Common Cold 88 Sore Throat 91 Pharyngitis 91 Sinusitis 92 Tonsillitis 94 Lower Respiratory System Infections 95 Laryngitis 95 Tracheitis 96 Croup 98 Infectious Bronchitis 99 Bronchiolitis 100 Influenza 102 Whooping Cough 105
The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration. Circulation.
Psittacosis 107 Pneumonia 108 Legionnaire Disease 113 Tuberculosis 114 Chapter 5: Diseases and Disorders of the Respiratory System 122 Disorders of the Upper Airway 122 Snoring 123 Sleep Apnea 124 Pickwickian Syndrome 126 Diseases of the Pleura 126 Pleurisy 127 Pleural Effusion and Thoracic Empyema 127 Pneumothorax 129 Diseases of the Bronchi and Lungs 130 Bronchiectasis 130 Chronic Bronchitis 131 Pulmonary Emphysema 133 Chronic Obstructive Pulmonary Disease 136 Lung Congestion 138 Atelectasis 141 Lung Infarction 144 Cystic Fibrosis 145 Idiopathic Pulmonary Fibrosis 149 Sarcoidosis and Eosinophilic Granuloma 149 Pulmonary Alveolar Proteinosis 150 Immunologic Conditions of the Lung 151 Lung Cancer 152 Diseases of the Mediastinum and Diaphragm 156
Chapter 6: Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 159 Allergic Lung Diseases 159 Asthma 160 Hay Fever 164 Hypersensitivity Pneumonitis 166 Occupational Lung Disease 167 Silicosis 169 Black Lung 170 Asbestosis and Mesothelioma 171 Respiratory Toxicity of Glass and Metal Fibres 173 Byssinosis 174 Respiratory Toxicity of Industrial Chemicals 175 Disability and Attribution of Occupational Lung Diseases 176 Other Respiratory Conditions 177 Circulatory Disorders 177 Respiratory Distress Syndrome 179 Air Pollution 180 Carbon Monoxide Poisoning 183 Acidosis 184 Alkalosis and Hyperventilation 184 Hypoxia 186 Altitude Sickness 188 Barotrauma and Decompression Sickness 189 Thoracic Squeeze 192 Drowning 193 Chapter 7: Approaches to Respiratory Evaluation and Treatment 196 Recognizing the Signs and Symptoms of Disease 196
Methods of Investigation 199 Pulmonary Function Test 202 Chest X-ray 203 Lung Ventilation/Perfusion Scan 204 Bronchoscopy 205 Mediastinoscopy 208 Types of Respiratory Therapy 210 Drug Therapies 211 Oxygen Therapy 214 Artificial Respiration 218 Thoracentesis 220 Hyperbaric Chamber 221 Lung Transplantation 223 Conclusion 223
Glossary 226 Bibliography 228 Index 230
and moistening inhaled air. air travels through the trachea. Inside the lungs. also known as the windpipe. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. the cone-shaped passageway leading from the mouth and nose to the larynx. However. humans could not survive on Earth. the most prominent feature of the lung interior are the many small air passages called
. The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. This book explains the science behind the amazing human respiratory system. the air is cleansed and moistened before entering the lungs. After passing through the larynx. Air that passes through the nose travels to the pharynx. warming. or voice box. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. A thin membranous sac known as the pleura covers the lungs. They pump vital oxygen through airways and into the bloodstream every second of every day. This structure provides humans with the sense of smell while also filtering. whether by a viral or bacterial infection or through detrimental habits such as smoking. the centre of the respiratory system. or throat. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. The right lung has 10 airway segments. there are numerous nerves and blood vessels.7
he human lungs are amazing feats of nature. Here. The clean air then travels into the deep tissues of the lungs. The larynx is a hollow tube connected to the top of the windpipe. eventually reaching the region where gas is exchanged. Without this ability. It also sheds light on how easily a healthy respiratory system can be damaged. But there are many treatments to keep the airways free and clear. and the left lung has 8 to 10.
comprises the network of blood vessels supporting the conducting airways themselves. and to the left atrium of the heart. Thus. which look like cells in a honeycomb. the oxygenated blood is pumped to the rest of the body. which range in diameter from 3 mm (0. which makes exchanging gases easier. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. through the pulmonary arteries. The average adult lung has approximately 300 million alveoli. The act of breathing. air. the pulmonary system. thereby delivering oxygen and other nutrients to organs distant from the lungs. The first of these. Lungs also have two distinct blood circulation systems. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli.7
The Respiratory System
bronchioles. The second blood system in the lungs. humans and other animals do not need to actively think about breathing in order for it to happen. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs. through the pulmonary veins. the bronchial circulation. controlled by the brain. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the
. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. and tissue. is an automatic process. but still keeps them separate. or respiration. The bronchial circulation is a vital source of nourishment for the lung tissues. The gas-exchange area. From the heart.12 inch) to less than 1 mm (less than 0. the region where oxygen is transferred to the blood and carbon dioxide is removed. is made up of three separate compartments for blood.04 inch). The tissue compartment supports the air and blood compartments and lets them come into close contact.
others respond to chemical changes in the immediate external environment. 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. there also exist sensors that monitor the muscles that control breathing. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. These effects trigger an increase in respiration rate. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. metabolic rate and acid levels in muscle tissue increase. In the basic mechanics of breathing. One of the major abdominal muscles involved in breathing is the diaphragm. which are located throughout the body. metabolic rate slows and therefore respiration rate decreases and oxygen demand is low. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. When stimulated. The
. Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. thereby increasing oxygen delivery to tissues and maintaining the body’s acid–base balance. During exercise. during sleep. This fine level of regulation is fundamental in maintaining the acid–base balance in the body.7 Introduction
abdomen. these receptors constrict the airways and cause breathing to become fast and shallow. In addition to the types of sensors described above. air moves in and out of the lungs in response to pressure changes. respectively. This response represents the body’s attempt to prevent toxins from entering the lungs. which functions to move air in and out of the lungs as it contracts and relaxes. In contrast.
The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. The oxygen that the alveoli transfer to the blood is then circulated to the heart and the body’s other tissues. circulation. The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. oxygen is present at lower levels than it is at low altitudes. and metabolism all work together. during vigorous breathing. but it is assisted by a complex assembly of other muscle groups. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. The pulmonary alveoli. In adults. acclimatization. The amount of air that the lungs pump changes dramatically depending on external or internal conditions. People who live at high altitudes adapt to this decrease in oxygen availability. can cause the brain and the heart to stop functioning. Without oxygen. the small air spaces in the lungs. cells are unable to function properly. hiking up during the day and descending down to camp to
. Oxygen is used by cells for the breakdown of nutrients. which can lead to death. Respiration. in which the body works to more efficiently utilize oxygen in the air. an activity that is necessary to supply energy to the cells and the body. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. is a gradual process.7 The Respiratory System
diaphragm is the major muscle that facilitates breathing. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. At high altitudes. Oxygen deprivation. This exchange of gases takes place over an immense surface area. transfer carbon dioxide from and add oxygen to blood. However. even for only a few minutes. The main purpose of respiration is to provide oxygen for the body’s cells.
the body’s tissues become deprived of oxygen. This enables the body to adjust to the decreased availability of oxygen. certain viruses and fungi can also cause the disease. For example. pneumonia was a widespread and notoriously deadly disease. bacteria can cause inflammation of the trachea. If these precautions are not taken. a condition known as tracheitis. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing. The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. The
. which can be particularly dangerous in infants and in the elderly. which can lead to high-altitude pulmonary edema. and in the first decade of the 21st century. death is caused by drowning. as well as bacterial pneumonia. Before antibiotics were widely available. Pneumonia also often affects persons with impaired immune systems. it was a leading cause of death. In the lower respiratory system. as climbers make their way up the mountain. because these individuals are unable to defend against infectious organisms. In the 18th and 19th centuries. many people have their tonsils removed after suffering from chronic tonsillitis.7 Introduction
sleep at night. Inflammation of respiratory tissues can sometimes be severe and chronic. Essentially. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. Tuberculosis is another example of a respiratory disease caused by bacteria. Although bacteria sometimes cause pneumonia. Other common upper respiratory conditions include sore throat and pharyngitis. in which the body circulates additional blood to the lungs. which can arise as a result of infection. but the blood leaks into the air sacs.
One of the deadliest influenza pandemics was that of 1918–19. headaches. or large cheese-like masses. Sleep apnea causes affected individuals to awaken periodically through the night. in which the collapse of the airways leads to intermittent stoppages in breathing. Many respiratory conditions arise from noninfectious causes. Every few decades. One of the best-characterized inherited conditions is cystic fibrosis. Infection is accompanied by fever.7
The Respiratory System
tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). a strain of influenza virus gives rise to a pandemic.” and thus is used to describe diseases of uncertain origin. snoring is caused by blocked airways. This process leads to the eventual breakdown of respiratory tissues. Influenza is a common. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. One example is idiopathic pulmonary fibrosis. Eventually. chills. For example. It is a highly contagious disease too. sticky mucus that blocks the airways and the digestive tract. blood vessels in the lungs burst. which caused between 25 million and 50 million deaths worldwide. despite extensive research. The term idiopathic means “of unknown cause. seasonal respiratory illness that is caused by viral infection. resulting in the formation of cavities in the lungs. the primary symptom of which is the production of a thick. For some diseases of the respiratory system. Lung cancer can arise as a result of a
. A respiratory disease of major concern in the world today is lung cancer. Some respiratory diseases are inherited. which may be associated with obesity. no cause has been identified. which results in progressive shortness of breath until a person can no longer breathe. muscle pains. to form. A severe form of snoring is sleep apnea. and the infected person coughs up bright red blood. and stomach pain.
In the early 20th century. factors. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. have been around for years and are readily available. or work. Many treatments. Breathing asbestos can also cause the cancerous condition known as mesothelioma.3 million fatalities each year. Now. more than 7 percent of children and 9 percent of adults suffer from asthma. resulting in an estimated 1. lung cancer is the leading cause of cancer deaths worldwide. and even cockroaches. however. Construction workers and insulators exposed to asbestos often suffer from asbestosis. Breathing problems caused by allergies to environmental conditions are fairly common. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. which affects coal miners who inhale coal dust for many years. however. although tobacco smoking is the primary cause. it was still considered rare. particularly pneumonia and tuberculosis. There is hope for those who suffer from respiratory diseases and disorders. Nasal decongestants and antihistamines are examples of commonly used remedies. In addition to vaccines and antivirals. Doctors first described the symptoms of lung cancer in the mid-19th century. or white lung disease. 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. Several vaccines have been developed to prevent illnesses such as influenza.
. tobacco smoke. Some respiratory diseases arise as a result of occupational. Scientists are constantly researching and developing new and different treatments for respiratory ailments. The best-known occupational lung disease is black lung. Today.7 Introduction
variety of factors. most likely resulting from exposure to air pollution.
chemotherapy. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant. which can identify mutations that render some lung cancers susceptible to certain drugs. A healthy set of lungs is nothing to take for granted.7
The Respiratory System
Lung cancer treatments may consist of surgery. The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. the human respiratory system is a finely tuned feat of engineering. Treatment may also be based on the results of genetic screening. and the consequences of neglecting or damaging that fragile system can be drastic.
. As this book shows. and radiation.
the stem bronchi. and all the airways that branch extensively within the lungs.
the design of the respiratory systeM
The human gas–exchanging organ. where its delicate tissues are
. is located in the thorax (or chest). The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. Breathing. These actions encompass not only muscular movements but also cellular and chemical processes. or respiration. The respiratory system consists of two divisions: upper airways and lower airways. such as the intrapulmonary bronchi. just at the top of the larynx (or voice box). is fundamental to survival. the lung. The lower airway system consists of the larynx. the pharynx (or throat). Yet. it is otherwise an automatic process. supporting this process are a number of complex actions that occur within our bodies. and the alveolar ducts. occurring without our having to think about it. and part of the oral cavity. and though we possess the ability to consciously control the rate of our breathing. the trachea. the bronchioles.CHAPTER1
ANATOMY AND FUNCTION OF THE HUMAN RESPIRATORY SYSTEM
ur respiratory system provides us with the fundamental ability to breathe: to inhale and exhale air from our lungs. The upper airway system comprises the nose and the paranasal cavities (or sinuses). as simple as it is for us to inhale and exhale.
called conducting airways. carbon dioxide.7 The Respiratory System
The lungs serve as the gas-exchanging organ for the process of respiration.
protected by the bony and muscular thoracic cage. Encyclopædia Britannica. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product. Inc.
. Atmospheric air is pumped in and out regularly through a system of pipes.
is sometimes also considered a part of the upper airways. The muscles expand and contract the internal space of the thorax. the pumping action on the lung.
Morphology of the upper airways
The nose. which pumps blood from the heart to the lungs and the rest of the body. through which air may be inhaled or exhaled.e. The oral cavity. The filtering process is vital to clearing inhaled air of dust and other debris. sinuses. and the circulatory system (i. as the main respiratory muscle. and it protects against the passage into the lungs of potentially infectious foreign agents. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract.. such as enabling the sensation of smell. In addition to fulfilling a fundamental role in respiration. which acts as a carrier of gases. the heart and the blood vessels). the nasal cavity.
The nose is the external protuberance of an internal space. and the intercostal muscles of the chest wall play an essential role by generating. whose bony framework is formed by the ribs and the thoracic vertebrae. the nasal
. the structures of the upper respiratory tract also have other important functions. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall.7
Anatomy and Function of the Human Respiratory System
which connect the gas–exchange region inside the body with the environment outside the body. For respiration. Other elements fundamental to the process of respiration include the blood. under the control of the central nervous system. The diaphragm. the collaboration of other organ systems is essential.
The complex shape of the nasal cavity results from projections of bony ridges. and they reach their final size around age 20. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. The floor of the nasal cavity is formed by the palate. it is also flooding the nasal cavity. Each canal opens to the face by a nostril and into the pharynx by the choana. with the lacrimal apparatus in the corner of the eye. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. the frontal sinus. the ethmoid sinuses. which is the largest cavity. and they serve as resonance chambers for the human voice. and inferior nasal meatuses. The passageways thus formed below each ridge are called the superior. they help keep the weight of the skull within reasonable limits. the superior. The sinuses are located in four different skull bones: the maxilla. The paranasal sinuses are sets of paired single or multiple cavities of variable size. Correspondingly. which is located in the upper posterior wall of the nasal cavity. the epithelium. Its top cell layer. This structural design
. The duct drains the lacrimal fluid into the nasal cavity. and inferior turbinate bones (or conchae). middle. Most of their development takes place after birth. middle. they are called the maxillary sinus. via the nasolacrimal duct. ethmoid. and sphenoid bones. frontal. and the sphenoid sinus. ciliated and secreting cells. from the lateral wall. The sinuses have two principal functions: because they are filled with air. which also forms the roof of the oral cavity.7
The Respiratory System
septum. the mucosa of the nose contains mucus-secreting glands and venous plexuses. On each side. Typically. consists principally of two cell types. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also.
Anatomy and Function of the Human Respiratory System
Sagittal view of the human nasal cavity. moisten.
reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. is lined by skin that bears short thick hairs called vibrissae. a process that saves water and energy. They clean. About two dozen olfactory nerves convey the sensation of smell from the
. and warm the inspired air. During expiration through the nose. at the entrance of the nose. the air is dried and cooled. the olfactory organ with its sensory epithelium checks the quality of the inspired air. preparing it for intimate contact with the delicate tissues of the gas-exchange area. In the roof of the nose. Encyclopædia Britannica. Two regions of the nasal cavity have a different lining. Inc.
.7 The Respiratory System
olfactory cells through the bony roof of the nasal cavity to the central nervous system. the pharynx can be divided into three floors. The upper floor.
For the anatomical description. Inc. Encyclopædia Britannica. the nasopharynx. In the posterior wall of the
Sagittal section of the 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. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. is primarily a passageway for air and secretions from the nose to the oral pharynx.
Also residing within the thoracic cavity is the tracheobronchial tree: the heart. it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx. controls the traffic of air and food. which is the second–largest hollow space of the body. the pharyngeal tonsil. The cavity is enclosed by the ribs. which roofs the posterior part of the oral cavity. during the act of swallowing. 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 lower floor of the pharynx is called the hypopharynx. a cartilaginous. The lungs reside within the thoracic cavity (chest cavity). and food from the oral cavity is routed to the esophagus directly behind the larynx. the great arteries bringing blood from the heart out into general circulation.
Morphology of the lower airways
The major structures of the lower airways include the larynx. the vertebral column.7
Anatomy and Function of the Human Respiratory System
nasopharynx is located a lymphatic organ. It is delimited from the nasopharynx by the soft palate. When it is enlarged (as in tonsil hypertrophy). Its anterior wall is formed by the posterior part of the tongue. while the lungs themselves receive the air and facilitate the process of gas exchange. functions as a lid to the larynx and.
. The first two of these provide a canal for the passage of air to the lungs. the diaphragm. the vessels transporting blood between the heart and the lungs. Lying directly above the larynx. The epiglottis. it may interfere with nasal respiration and alter the resonance pattern of the voice. and lungs. leafshaped flap. trachea. The middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx.
the two surfaces tend to touch. when it occurs. most of them minute. or serum. and over part of the esophagus. Control is achieved by a number of muscles innervated by the laryngeal nerves. The chest cavity is lined with a serous membrane. and the great vessels. The pleural cavity is the space. the heart. For the precise function of the muscular apparatus. so called because it exudes a thin fluid. interconnected by ligaments and membranes. As evidenced by trained singers. the muscles must be anchored to a stabilizing framework.7
The Respiratory System
and the major veins into which the blood is collected for transport back to the heart. The laryngeal skeleton consists of almost a dozen pieces of cartilage. is made of two plates fused
. where it is called the visceral pleura. between the parietal and the visceral pleura. and as the organ of phonation. this function can be closely controlled and finely tuned. This causes not only the vocal cords but also the column of air above them to vibrate. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. This portion of the chest membrane is called the parietal pleura. as the mediastinal pleura. the glottis. the thyroid cartilage. the mediastinum being the space and the tissues and structures between the two lungs. The membrane continues over the lung. The largest cartilage of the larynx. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. Sound is produced by forcing air through a sagittal slit formed by the vocal cords.
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.
Viewed frontally. the thyroid notch. The cricoid is located below the thyroid cartilage. they follow its tilting movement. Both of these structures are easily felt through the skin. the laryngeal prominence.7
Anatomy and Function of the Human Respiratory System
anteriorly in the midline. 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. which has given this structure the common name of Adam’s apple. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. made of elastic tissue. below it is a forward projection. Because the arytenoid cartilages rest upright on the cricoid plate. the lumen of the laryngeal tube has an hourglass shape. the epiglottis is also attached to the back of the thyroid plate by its stalk. The cricoid. Like the true vocal cords. The transverse axis of the joint allows a hingelike rotation between the two cartilages. the vocal cords span the laryngeal lumen. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. they are also formed by the free end
. The vocal ligaments are part of a tube. 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. This mechanism plays an important role in altering length and tension of the vocal cords. has a signet-ring shape. Just above the vocal cords. At the upper end of the fusion line is an incision. another large cartilaginous piece of the laryngeal skeleton. Behind the shieldlike thyroid cartilage. the arytenoid cartilages. to which it is joined in an articulation reinforced by ligaments. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. with its narrowest width at the glottis.
is oriented more vertically. The interior of the trachea is lined by the typical respiratory epithelium. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. the trachea divides in an inverted Y into the two stem (or main) bronchi. and tension of the vocal cords.g.8 inch) wide. The extrinsic muscles act on the larynx as a whole.
The Trachea and the Stem Bronchi
Below the larynx lies the trachea. The dorsal wall contains a strong layer of transverse smooth muscle fibres that spans the gap of the cartilage. The mucosal layer contains mucous glands. The intrinsic muscles act directly or indirectly on the shape. Because the gap between the vestibular folds is always larger than the gap between the vocal cords. one each for the left and right lung. an instrument designed for visual inspection of the interior of the larynx. length. This space is called the ventricle of the larynx. At its lower end. and is shorter than the left main bronchus. The practical consequence of
. The intrinsic muscles attach to the skeletal components of the larynx itself. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. moving it upward (e.7
The Respiratory System
of a fibroelastic membrane. during high-pitched phonation or swallowing) or downward.. The right main bronchus has a larger diameter. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. Between the vestibular folds and the vocal cords. The muscular apparatus of the larynx comprises two functionally distinct groups. the laryngeal space enlarges and forms lateral pockets extending upward. the latter can easily be seen from above with the laryngoscope.
the daughter branches may differ greatly in length and diameter. Individual paths.
structural design of the airway tree
The hierarchy of the dividing airways. purely conducting zone. The structure of the stem bronchi closely matches that of the trachea. the intrapulmonary airway system can be subdivided into three zones: a proximal. and a transitional zone in between. From a morphological point of view. if the trachea is counted as generation zero. however. it makes sense to distinguish the relatively thick-walled. a peripheral. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. may range from 11 to 30 generations. where both functions grade into one another. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. In modeling the human airway tree. In irregular dichotomy. purely gas-exchanging zone. it is generally agreed that the airways branch according to the rules of irregular dichotomy. however. largely determines the internal lung structure. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. Functionally. and partly also of the blood vessels penetrating the lung.7
Anatomy and Function of the Human Respiratory System
this arrangement is that foreign bodies passing beyond the larynx will usually slip into the right lung.
. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions. however.
In the alveoli. After several generations of such respiratory bronchioles. gain their stability from their structural integration into the gas-exchanging tissues. and the bronchioles. This design can be compared to a conveyor belt for particles. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. Ciliated cells are present far down in the airway tree. The epithelium is covered by a layer of low-viscosity fluid. the bronchi. as does the frequency of goblet cells. devoid of cartilage. within which the cilia exert a synchronized. and indeed the mechanism is referred to as the mucociliary escalator. the alveoli are so densely packed along the airway that an airway wall
. where they are swallowed. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. Their function is to further warm. the walls of the bronchioles. the two stem bronchi. this fluid layer is topped by a blanket of mucus of high viscosity. their height decreasing with the narrowing of the tubes. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path.7
The Respiratory System
The conducting airways comprise the trachea. rhythmic beat directed outward. The last purely conductive airway generations in the lung are the terminal bronchioles. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. moisten. Distally. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. In larger airways. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells.
which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. a superior. and nerves enter or leave the lungs. The left lung. The right and left lungs are slightly unequal in size. the trachea with the stem bronchi. the esophagus. a circumscribed area where airways. separated from each other by a deep horizontal and an oblique fissure. and the airway consists of alveolar ducts. which corresponds to a connective tissue space containing the heart. The space between them is filled by the mediastinum. they are connected with the mediastinum at the hilum.
Humans have two lung organs.
Together. The parietal pleura and the visceral pleura that line the inside
. The right lung represents 56 percent of the total lung volume and is composed of three lobes. middle.7
Anatomy and Function of the Human Respiratory System
proper is missing. and the thymus gland. In the thorax. while their apexes extend above the first rib. major blood vessels. The final generations of the airway tree end blindly in the alveolar sacs. blood and lymphatic vessels. the lungs occupy most of the intrathoracic space. In humans each lung is encased in a thin membranous sac called the pleura. the two lungs rest with their bases on the diaphragm. has only two lobes separated by an oblique fissure. 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. Medially. a right and a left. and inferior lobe.
7 The Respiratory System
Anatomy of the human lungs. Encyclopædia Britannica. During inspiration. Depending on the subjacent structures. the parietal pleura can be subdivided into three portions: mediastinal. A thin film of extracellular fluid between the pleurae enables
. Although the hilum is the only place where the lungs are secured to surrounding structures. so the pleural cavity is larger than the lung volume. costal. are in direct continuity at the hilum.
of the thoracic cavities and the lung surface. respectively. the recesses are partly opened by the expanding lung. Inc. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. and diaphragmatic pleurae. The presence of pleural recesses form a kind of reserve space. thus allowing the lung to increase in volume.
a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. These anatomical features are important because pathological processes may be limited to discrete units. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. the lung immediately collapses owing to its inherent elastic properties. depending on the classification. Bronchioles are
. Furthermore. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. This outer fibrous layer contains. Unlike the lobes. There are 10 segments in the right lung and 8 to 10 segments in the left lung. the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics.
The lung lobes are subdivided into smaller units.
The Bronchi and Bronchioles
In the intrapulmonary bronchi. and the surgeon can remove single diseased segments instead of whole lobes. and breathing is abolished on this side. besides lymphatics and nerves. the arterial supply follows the segmental bronchi. If the serous membranes become inflamed (pleurisy). The bronchi are ensheathed by a layer of loose connective tissue that is continuous with the other connective tissue elements of the lung and hence is part of the fibrous skeleton spanning the lung from the hilum to the pleural sac. If air enters a pleural cavity (pneumothorax). the pulmonary segments.7
Anatomy and Function of the Human Respiratory System
the lungs to move smoothly along the walls of the cavity during breathing. respiratory movements can be painful.
The Respiratory System
small conducting airways ranging in diameter from three to less than one millimetre. The gas-exchange tissue proper is called the pulmonary parenchyma. which produce secretions. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. capable of narrowing the airway. and tissue. in the last generation. conductive airways. blood. The airways are then called alveolar ducts and. and vice versa. the frequency of alveolar outpocketings increases rapidly. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. The walls of the bronchioles lack cartilage and seromucous glands. through the 160 square metres (about 1. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. until after two to four generations of respiratory bronchioles. the whole wall is formed by alveoli. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. an adult human lung has about 300 million alveoli. The respiratory gases diffuse from air to blood. Distally. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. Whereas air and blood are continuously replenished. lymphatics. alveolar sacs. and non-capillary blood vessels belong to the non-parenchyma. while the supplying structures.722 square feet) of internal surface area of the tissue compartment. with a
The Gas-Exchange Region
The gas-exchange region comprises three compartments: air. They are polyhedral structures.
covers between 92 and 95 percent of the gas-exchange surface. Type II pneumocytes produce a surface-tension-reducing material. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. or cell debris originating from cell damage or normal cell death. The interalveolar septum is covered on both sides by the alveolar epithelial cells. and a skeleton of connective tissue fibres. It contains a dense network of capillaries. They are large cells. the type I pneumocyte. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing.7
Anatomy and Function of the Human Respiratory System
diameter of about 250 to 300 micrometres. squamous cell type. The alveolar wall. the type II pneumocyte. together with the endothelial cells. the alveolar macrophages are derived from the bone marrow. called the interalveolar septum. and their task is to keep the air–blood barrier clean and unobstructed. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. is common to two adjacent alveoli. covers the remaining surface. the thin air–blood barrier for gas exchange. Ultimately. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. and their cell bodies abound in granules of various content. where they connect to the airway. It contains connective tissue and interstitial
. A thin. These granules are the conspicuous ultrastructural features of this cell type. a second. the smallest of the blood vessels. The type I cells form. partly foreign material that may have reached the alveoli. more cuboidal cell type. alveolar macrophages creep around within the surfactant fluid. whereas type II cells are secretory. and open on one side. On top of the epithelium. Before it is released into the airspaces. the pulmonary surfactant.
small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. and cells (mainly fibroblasts). and Nerves
With respect to blood circulation.
Blood Vessels. the pulmonary arteries. The oxygenated blood from the capillaries is collected by
. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. which seem to be endowed with contractile properties. the lung is a complex organ. which have on average a pressure five times lower than systemic arteries. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. As a consequence. are much flimsier than systemic arteries of corresponding size. the respiratory gases must diffuse across longer distances. The fibroblasts are thought to control capillary blood flow or. and proper functioning of the lung is severely jeopardized. Lymphatic Vessels. The connective tissue comprises a system of fibres.7
The Respiratory System
fluid. following relatively closely the course of the dividing airway tree. alternatively. This pathological condition is called pulmonary edema. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. After numerous divisions. amorphous ground substance. Blood. Because intravascular pressure determines the arterial wall structure. On each side. low in oxygen content but laden with carbon dioxide. is carried from the right heart through the pulmonary arteries to the lungs. to prevent the accumulation of extracellular fluid in the interalveolar septa. an excess of fluid accumulates in the lung tissue and within the airspaces.
Within the lung and the mediastinum. Small bronchial veins exist. they end several generations short of the terminal bronchioles. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. The interlobular veins then converge on the intersegmental septa. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart. Generally. The superficial. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. With a few exceptions. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. called bronchomediastinal trunks. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. Finally. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. They are small vessels and generally do not reach as far into the periphery as the conducting airways. The bronchial arteries originate from the aorta or from an intercostal artery. however. 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.7
Anatomy and Function of the Human Respiratory System
venules and drained into small veins. Most of their blood is naturally collected by pulmonary veins. Lymph drainage
The Respiratory System
paths from the lung are complex. The precise knowledge of their course is clinically relevant, because malignant tumours of the lung spread via the lymphatics. The pleurae, the airways, and the vessels are innervated by afferent and efferent fibres of the autonomic nervous system. Parasympathetic nerve fibres from the vagus nerve (10th cranial nerve) and sympathetic branches of the sympathetic nerve trunk meet around the stem bronchi to form the pulmonary autonomic nerve plexus, which penetrates into the lung along the bronchial and vascular walls. The sympathetic fibres mediate a vasoconstrictive action in the pulmonary vascular bed and a secretomotor activity in the bronchial glands. The parasympathetic fibres stimulate bronchial constriction. Afferent fibres to the vagus nerve transmit information from stretch receptors, and those to the sympathetic centres carry sensory information (e.g., pain) from the bronchial mucosa.
After early embryogenesis, during which the lung primordium is laid down, the developing human lung undergoes four consecutive stages of development, ending after birth. The names of the stages describe the actual morphology of the prospective airways. The pseudoglandular stage exists from 5 to 17 weeks; the canalicular stage, from 16 to 26 weeks; the saccular stage, from 24 to 38 weeks; and finally the alveolar stage, from 36 weeks of fetal age to about 1 ½ to 2 years after birth. The lung appears around the 26th day of intrauterine life as a ventral bud of the prospective esophagus. The bud separates distally from the gut, divides, and starts to grow into the surrounding mesenchyme. The epithelial components of the lung are thus derived from the gut (i.e., they
Anatomy and Function of the Human Respiratory System
are of endodermal origin), and the surrounding tissues and the blood vessels are derivatives of the mesoderm. Following rapid successive dichotomous divisions, the lung begins to look like a gland, giving the first stage of development (pseudoglandular) its name. At the same time the vascular connections also develop and form a capillary plexus around the lung tubules. Toward week 17, all the conducting airways of the lung are preformed, and it is assumed that, at the outermost periphery, the tips of the tubules represent the first structures of the prospective gas-exchange region. During the canalicular stage, the future lung periphery develops further. The prospective airspaces enlarge at the expense of the intervening mesenchyme, and their cuboidal epithelium differentiates into type I and type II epithelial cells or pneumocytes. Toward the end of this stage, areas with a thin prospective air–blood barrier have developed, and surfactant production has started. These structural and functional developments give a prematurely born fetus a small chance to survive at this stage. During the saccular stage, further generations of airways are formed. The tremendous expansion of the prospective respiratory airspaces causes the formation of saccules and a marked decrease in the interstitial tissue mass. The lung looks more and more “aerated,” but it is filled with fluid originating from the lungs and from the amniotic fluid surrounding the fetus. Some weeks before birth, alveolar formation begins by a septation process that subdivides the saccules into alveoli. At this stage of lung development, the infant is born. At birth the intrapulmonary fluid is rapidly evacuated and the lung fills with air with the first breaths. Simultaneously, the pulmonary circulation, which before was practically bypassed and very little perfused, opens up to accept the full cardiac output.
The Respiratory System
The newborn lung is far from being a miniaturized version of the adult lung. It has only about 20 million to 50 million alveoli, or 6 to 15 percent of the full adult complement. Therefore, alveolar formation is completed in the early postnatal period. Although it was previously thought that alveolar formation could continue to age eight and beyond, it is now accepted that the bulk of alveolar formation is concluded much earlier, probably before age two. Even with complete alveolar formation, the lung is not yet mature. The newly formed interalveolar septa still contain a double capillary network instead of the single one of the adult lungs. This means that the pulmonary capillary bed must be completely reorganized during and after alveolar formation to mature. Only after full microvascular maturation, which is terminated sometime between ages two and five, is the lung development completed, and the lung can enter a phase of normal growth.
CONTROL AND MECHANICS OF BREATHING
he respiratory system is intimately associated with the brain and central nervous system. Indeed, the diaphragm and the muscles of the chest are innervated by neurons that connect to regions of the brain known as the pons and medulla oblongata. These regions are involved in the control of autonomic nervous activity and therefore regulate internal organs without any conscious recognition or effort. Thus, breathing is an automated function in which nerve impulses sent from the brain stimulate the respiratory muscles to contract, thereby producing the mechanical forces associated with inhalation and exhalation. These impulses give rise to every breath, and in healthy individuals they are sent faithfully for life.
control of breathing
Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. The respiratory rhythm and the length of each phase of respiration are set by reciprocal stimulatory and inhibitory interconnection of these brain-stem neurons. An important characteristic of the human respiratory system is its ability to adjust breathing patterns to changes in both the internal milieu and the external environment. Ventilation increases and decreases in proportion to
These same muscles are used to perform a number of other functions. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. Breathing also undergoes appropriate adjustments when the mechanical advantage of the respiratory muscles is altered by postural changes or by movement. Although the use of these different muscle groups adds considerably to the flexibility of the breathing act.7
The Respiratory System
swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. and maintaining posture. breathing can be
. and muscles such as the scalene and sternocleidomastoid that attach both to the ribs and to the cervical spine at the base of the skull also play an important role in the exchange of air between the atmosphere and the lungs. Although the diaphragm is the major muscle of breathing. In addition. 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. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. they also complicate the regulation of breathing. Mechanoreceptors monitor the expansion of the lung. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. chewing and swallowing. such as speaking. such as the airway narrowing that occurs in an asthmatic attack. the force of respiratory muscle contraction. This flexibility in breathing patterns in large part arises from sensors distributed throughout the body that send signals to the respiratory neuronal networks in the brain. and the extent of muscle shortening. Intercostal muscles inserting on the ribs. abdominal muscles. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. the size of the airway.
Control and Mechanics of Breathing
Singing demands a strong diaphragm to control breath.
Input into the respiratory control system from higher brain centres may help optimize breathing so that not only are metabolic demands satisfied by breathing but ventilation also is accomplished with minimal use of energy.
central organization of respiratory neurons
The respiratory rhythm is generated within the pons and medulla. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. which supply the diaphragm and other thoracic and abdominal muscles. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration.7
The Respiratory System
influenced by higher brain centres and even controlled voluntarily to a substantial degree. in turn they drive cranial motor neurons. allowing the activity of these physiological systems to be coordinated with respiration. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. 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
. Neurally. 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.
offswitch. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. When the vagus nerves are sectioned or pontine centres are destroyed. This increase in activity. After a gap of a few milliseconds. which occasionally occurs in persons with diseases of the brain stem. inspiratory activity is restarted. As the activity of the post-inspiratory neurons subsides. is called apneustic breathing. which produces lung expansion. breathing is characterized by prolonged inspiratory activity that may last for several minutes. post-inspiratory. although in upright humans the lower expiratory intercostal muscles
. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. but at a much lower level. early inspiratory. expiratory neurons discharge and inspiratory neurons are strongly inhibited. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. Offswitch neurons in the medulla terminate inspiration. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity. and expiratory.7 Control and Mechanics of Breathing
abruptly. Then the cycle begins again. Mechanically. and gradually declines until the onset of expiratory neuron activity. It is believed by some that these post-inspiratory neurons have inhibitory effects on both inspiratory and expiratory neurons and therefore play a significant role in determining the length of the respiratory cycle and the different phases of respiration. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. This type of breathing.
which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. which restores partial pressures of oxygen and carbon dioxide to their usual levels. by a
. Moreover. As expiration proceeds. too much ventilation depresses the partial pressure of carbon dioxide. more expiratory intercostal and abdominal muscles contract. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. During sleep and anesthesia. Conversely.
Hypoxia. 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. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. or the reduction of oxygen supply to tissues to less than physiological levels (produced. and central chemoreceptors in the brain.7
The Respiratory System
and the abdominal muscles may be active even during quiet breathing. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea).
One way in which breathing is controlled is through feedback by chemoreceptors. as the demand to breathe increases (for example. There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. with exercise). 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.
The amplitude of these fluctuations. stimulates the carotid and aortic bodies. a branch of the glossopharyngeal nerve. Acetylcholine. responding more to rapid than to slow changes in the partial pressure of carbon dioxide. as reflected in the size of carotid body signals. The two carotid bodies are small organs located in the neck at the bifurcation of each of the two common carotid arteries into the internal and external carotid arteries. Fine sensory nerve fibres are found in juxtaposition to type I cells. contain electron-dense vesicles. The type II cells are generally not believed to have a direct role in chemoreception. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls. The type I cells are arranged in groups and are surrounded by type II cells.7 Control and Mechanics of Breathing
trip to high altitudes). This arterial blood parameter rises and falls as air enters and leaves the lungs. unlike type II cells. the carotid body consists of two different types of cells. In addition to responding to hypoxia. and the carotid body senses these fluctuations. vasoactive
. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. This organ is extraordinarily well perfused and responds to changes in the partial pressure of oxygen in the arterial blood flowing through it rather than to the oxygen content of that blood (the amount of oxygen chemically combined with hemoglobin). The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. and neuropeptides such as enkephalins. catecholamines. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. Microscopically. which. the principal arterial chemoreceptors. may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation.
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. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. are located within the vesicles. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide. Carbon dioxide increases the acidity of the fluid surrounding the cells but also easily passes into cells and thus can make the interior of cells more acidic. Even if both the carotid and aortic bodies are removed. As the partial pressure of carbon dioxide in arterial blood rises.7
The Respiratory System
intestinal peptide. Current thinking places these receptors near the undersurface (ventral part) of the
. and substance P. ventilation increases nearly linearly. inhaling gases that contain carbon dioxide stimulates breathing. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity. The aortic bodies located near the arch of the aorta also respond to acute changes in the partial pressure of oxygen.
Carbon dioxide is one of the most powerful stimulants of breathing. 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. which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. but less well than the carotid body responds to changes in the partial pressure of carbon dioxide.
in the respiratory muscles measure muscle length and increase motor discharge to the diaphragm and intercostal muscles when increased stiffness of the lung or resistance to the movement of air caused by disease impedes muscle shortening. Tendon organs. Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. 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. monitor changes in the force produced by muscle contraction. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves.
Muscle and Lung Receptors
Receptors in the respiratory muscles and in the lung can also affect breathing patterns. The Hering-Breuer reflex is initiated by lung expansion. Generally. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. called spindles. Changes in the length of a muscle affect the force it can produce when stimulated. which excites stretch receptors in the airways. there is a length at which the force generated is maximal. These receptors are particularly important when lung function is impaired. another receptor in muscles.
. because they can help maintain tidal volume and ventilation at normal levels. Receptors.7 Control and Mechanics of Breathing
medulla. Stimulation of these receptors. They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain.
shortens inspiratory times as tidal volume (the volume of air inspired) increases. the association between sleep and breathing is more complicated than this because brain activity changes as a person progresses through the different stages of sleep. This in turn leads to fluctuations in breathing patterns. during sleep. others (the J receptors) by unmyelinated fibres. increased levels of oxygen are needed to fuel muscle function.
Variations in breathing
Variations in breathing result from changes in metabolic demands in the tissues of the body. during exercise. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. the reflex allows inspiratory time to be lengthened. accelerating the frequency of breathing. helping to preserve tidal volume. These receptors are supplied. by the vagus nerve. which inhibits the penetration of injurious agents into the bronchial tree. bradykinin. these receptors constrict the airways and cause rapid shallow breathing. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. like the stretch receptors. At the opposite end of the spectrum. The most important function of these receptors. however.
The Respiratory System
which send signals to the medulla by the vagus nerve. the body’s metabolic rate slows. For example. and thus breathing typically becomes lighter. may be to defend the lung against noxious material in the atmosphere. When stimulated. and prostaglandins. Stimulation of irritant receptors also causes coughing. When lung inflation is prevented.
and thermal receptors. the arterial chemoreceptors.7 Control and Mechanics of Breathing
One of the remarkable features of the respiratory control system is that ventilation increases sufficiently to keep the partial pressure of carbon dioxide in arterial blood nearly unchanged despite the large increases in metabolic rate that can occur with exercise. and thermal receptors all work in concert during exercise to enhance ventilation.
Mechanoreceptors. thus preserving acid–base homeostasis. Sources of these signals include mechanoreceptors in the exercising limbs. A number of signals arise during exercise that can augment ventilation. because body temperature rises as metabolism increases. arterial chemoreceptors. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide.com 51
or even apnea (cessation of breathing). Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness. whereas in rapid eye movement sleep. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons.
. Changes in the concentration of potassium and lactic acid in the exercising muscles acting on unmyelinated nerve fibres may be another mechanism for stimulation of breathing during exercise. but there is an even greater decline in ventilation so that the partial pressure of carbon dioxide in arterial blood rises slightly and arterial partial pressure of oxygen falls. but it may entail unstable feedback regulation of breathing.7
The Respiratory System
The brain also seems to anticipate changes in the metabolic rate caused by exercise. Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. In slow-wave sleep. The effects on ventilatory pattern vary with sleep stage. This rhythmic waxing and waning of breathing. It remains unclear. how these various mechanisms are adjusted to maintain acid–base balance. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. with intermittent periods of apnea. however. breathing can become quite erratic. During sleep. after the physicians who first described it. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. is called Cheyne-Stokes breathing.
During sleep. breathing is diminished but remains regular. body metabolism is reduced.
portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids. sleep is of poor quality. In some individuals. Many of the upper airway muscles. In some persons with sleep apnea syndrome. and the reduced activity of these muscles during sleep may lead to upper airway closure. Snoring and disturbed behaviour during sleep may also occur. The condition. Because atmospheric pressure remains relatively constant. When the air pressure within the alveolar spaces falls below atmospheric pressure. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. flow is determined by how
. ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. however. provided the larynx is open. and in the obese. undergo phasic changes in their electrical activity synchronous with respiration. air enters the lungs (inspiration). which increase the likelihood of obstruction. air is blown from the lungs (expiration). termed sleep apnea syndrome.7 Control and Mechanics of Breathing
In addition. like the tongue and laryngeal adductors. leading to severe drops in the levels of blood oxygenation. Others. in males.
the Mechanics of breathing
Air moves in and out of the lungs in response to differences in pressure. and complaints of excessive daytime drowsiness are common. in the newborn. this intermittent obstruction occurs repeatedly during the night. have normal upper airway anatomy. When the air pressure within the alveoli exceeds atmospheric pressure. occurs most commonly in the elderly. Because arousal is often associated with the termination of episodes of obstruction.
the volume of chest and lungs
. A difference in air pressure between atmosphere and lungs is created. Each small increment of expansion transiently increases the space enclosing lung air.7
The Respiratory System
The diaphragm contracts and relaxes. forcing air in and out of the lungs. less air per unit of volume in the lungs and pressure falls. There is. Encyclopædia Britannica. therefore. Inc. and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume. When the muscles of inspiration relax. 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.
much above or below atmospheric pressure the pressure within the lungs rises or falls.
thereby allowing the lung to separate from the chest at this particular spot. its pressure rises above atmospheric pressure. This. the pleural pressure reflects primarily two forces:
. The force also increases in proportion to the rapidity with which air is drawn into the lung and decreases in proportion to the force with which air is expelled from the lungs. The pressure measured in the small pleural space so created is substantially below atmospheric pressure at a time when the pressure within the lung itself equals atmospheric pressure. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. In summary. therefore. A lung is similar to a balloon in that it resists stretch. then. 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. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. lung air becomes transiently compressed.
The Lung–Chest System
The forces that normally cause changes in volume of the chest and lungs stem not only from muscle contraction but from the elastic properties of both the lung and the chest. resulting in flow of air into or out of the lung and establishment of a new lung volume. This negative (below-atmospheric) pressure is a measure. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. of the force required to keep the lung distended. The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration.7 Control and Mechanics of Breathing
During inspiration. the additional retraction of lung returns the system to its equilibrium position. Because the pleural pressure is below atmospheric pressure. air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. these would collapse. as by a wound or by a surgical incision. And were it not for the inward traction of the lungs on the chest and diaphragm. Were it not for the outward traction of the chest on the lungs. thereby further raising the diaphragm and causing forceful expiration.7
The Respiratory System
1. The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. The lung– chest system thus acts as two opposed coiled springs. This additional muscular force is removed on relaxation
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. When these muscles relax. the length of each of which is affected by the other. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch. which are in turn stretched inward by the pull of the lungs. the force required to keep the lung inflated against its elastic recoil and 2. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. the force required to cause airflow in and out of the lung.
. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. muscular contraction occurs only on inspiration. During ordinary breathing.
The Respiratory Pump and Its Performance
The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. such as pieces of glass. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. separated by a film of water. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. At total relaxation of the muscles of inspiration and expiration. expiration being accomplished “passively” by elastic recoil of the lung. 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. capable of increasing its output 25 times.7 Control and Mechanics of Breathing
and the original lung volume is restored. The respiratory pump is versatile. The volume in these circumstances is known as the residual volume. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen.154 cubic inches) per minute in adults.
e.. normally reaching 30 litres per minute in quiet breathing.8 pounds per square inch) by the so-called Valsalva maneuver—a forceful contraction of the chest and abdominal muscles against a closed glottis (i. © www .istockphoto. The beating of cilia (hairline projections) from cells lining the airways
. can be raised voluntarily to 400 litres per minute.com / Jason Lugo
within the lungs can be raised to 130 centimetres of water (about 1. with no space between the vocal cords). The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver.7
The Respiratory System
A cough clears the airways with an abrupt opening of the larynx. Airflow velocity.
If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. 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.7 Control and Mechanics of Breathing
normally maintains a steady flow of secretions toward the nose. and seven litres. such adherence occasionally does occur and is one of the dreaded complications of premature births.
. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces. 500 millilitres. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. Normal lungs. totaling about 0. respectively. In fact.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths.
which is needed to support the functions of the body’s various tissues. the respiratory system. in exchange.5 micrometre. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and. however. transfer carbon dioxide to the alveoli. as well as other organ systems. Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane.722 square feet). This process of adaptation is necessary to maintain normal physiological function. adapt to variations in atmospheric pressure.
Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. The area of the alveolar surface in the adult human is about 160 square metres (1. The oxygen is then distributed by the blood to the tissues. about 0. At high altitudes or during activities such as deep-sea diving. whereas the carbon dioxide is expelled from the alveoli during exhalation. For inhaled oxygen to reach these tissues.CHAPTER3
GAS EXCHANGE AND RESPIRATORY ADAPTATION
nhaled air is rich in oxygen. or ¹/¹00 of the diameter of a human hair. 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.
7 Gas Exchange and Respiratory Adaptation
Changes in the atmosphere’s pressure occur when deep-sea diving and require the respiratory system to adapt.com 61
which in turn is responsive to overall body requirements. Local flows can be increased selectively. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. convection and diffusion. caused by differing modes of transport in the blood. In a mixture of gases. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. A gas will diffuse from an area of greater partial pressure to an area of lower partial pressure regardless of the distribution of the partial pressures of other gases. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. the partial pressure of each gas is directly proportional to its concentration. Diffusion is the primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. in the flow through skeletal muscles during exercise. but almost equal quantities of the two gases are involved in metabolism and gas exchange. Respiratory gases also move by diffusion across tissue barriers such as membranes. or mass flow. for example. Convection. The rapidity of circulation is determined by the output of the heart. as occurs. The performance of the heart and circula-
The Respiratory System
Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. The partial pressure of a gas in fluid is a measure of its tendency to leave the fluid when exposed to a gas or fluid that does not contain that gas. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues.
Gas Exchange and Respiratory Adaptation
tory regulation are.
transport of oxygen
Oxygen is poorly soluble in plasma. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. The curve representing the content of oxygen in blood at various partial pressures of oxygen. Most oxygen is bound to hemoglobin. so less than 2 percent of oxygen is transported dissolved in plasma. Enough hemoglobin is present in normal human blood to permit transport of about 0. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. therefore. called the oxygen-dissociation curve. 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. Not all of the oxygen transported in the blood is transferred to the tissue cells. The amount of oxygen
. 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. important determinants of gas transport.2 ml of oxygen per ml of blood. liquid portion of blood. the cell-free. Each iron atom can bind and then release an oxygen molecule. In alveoli at sea level. which make up 40 to 50 percent of the blood volume in most mammals. These systems are present mainly in the red cells. Plasma. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood.
with the binding of oxygen. (Affinity denotes the tendency of molecules of different species to bind to one another. Conversely. and 2. or 2. A rightward shift of the curve is thought to be of benefit in releasing oxygen to the tissues when needs are great in relation to oxygen delivery. and 2. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent.) Increases in hydrogen ions. and the curve is shifted
.3-DPG decrease the affinity of hemoglobin for oxygen.3-DPG. or pH. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. as occurs with anemia or extreme exercise. Hemoglobin binds not only to oxygen but to other substances as well. carbon dioxide. carbon dioxide. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances.7
The Respiratory System
extracted by the cells depends on their rate of energy expenditure. including hydrogen ions (which determine the acidity. Because of this decreased affinity. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. and the oxygen-dissociation curve shifts to the right. Reductions in normal concentrations of hydrogen ions. carbon dioxide. Although these substances do not bind to hemoglobin at the oxygen-binding sites.3-diphosphoglycerate (2. This reserve is available to meet increased oxygen demands. At rest. of the blood). binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen.3-DPG result in an increased affinity of hemoglobin for oxygen.
Complete elimination would lead to large changes in acidity between arterial and venous blood. principally hemoglobin.
. The remainder is found in reversible chemical combinations in red blood cells or plasma. enhanced release of oxygen). 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. Temperature changes affect the oxygen-dissociation curve similarly. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. whereas a decrease in temperature shifts the curve to the left (increased affinity). The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. remains unchanged and is transported dissolved in blood. blood normally remains in the pulmonary capillaries less than a second. Furthermore. The range of body temperature usually encountered in humans is relatively narrow. Some carbon dioxide binds to blood proteins. A small portion of carbon dioxide. so that temperature-associated changes in oxygen affinity have little physiological importance. as occurs at extreme altitude. 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.7
Gas Exchange and Respiratory Adaptation
to the left.
transport of carbon dioxide
Transport of carbon dioxide in the blood is considerably more complex. with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. An increase in temperature shifts the curve to the right (decreased affinity. an insufficient time to eliminate all carbon dioxide.
which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-). it combines with water to form carbonic acid (H2CO3 ). are effective buffering agents. a relatively weak acid. Carbonic anhydrase. essentially. As carbon dioxide enters the blood. Blood acidity is minimally affected by the released hydrogen ions because blood proteins.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. Shutterstock. a protein enzyme present inside the
The Respiratory System
Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water. especially hemoglobin.) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. (A buffer solution resists change in acidity by combining with added hydrogen ions and. inactivating them.
The simultaneous exchange of these two ions. however. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. while 62 percent exists as bicarbonate in plasma. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second. known as the chloride shift. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change
. where the partial pressure of carbon dioxide is lower than in the blood. 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. Thus. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. The bulk of bicarbonate ions is first produced inside the 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. A few amino sites on hemoglobin are oxylabile. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. 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. that is. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. Because the enzyme is present only inside the red blood cell.7
Gas Exchange and Respiratory Adaptation
red blood cell. then transported to the plasma. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. A reverse sequence of reactions occurs when blood reaches the lung.
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. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs.7
The Respiratory System
or binding. because of the increased size of inspired breaths. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise.
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. because only free carbon dioxide easily crosses biologic membranes. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of
. yet this pool is important. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. Under ideal circumstances. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. not all inspired air participates in gas exchange. and almost all blood entering the lungs participates in gas exchange. blood flow through the lung is continuous. Between these two events. Virtually every molecule of carbon dioxide produced by metabolism must exist in the free form as it enters blood in the tissues and leaves capillaries in the lung. most carbon dioxide is transported as bicarbonate or carbamate. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. In contrast to the cyclic nature of ventilation. In health.
g. In shunting. and limitations of diffusion. A reduction in arterial blood oxygenation is seen with shunting. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs.. ventilation– blood flow imbalance. Because of the differences in oxygen and carbon dioxide transport. venous blood enters the bloodstream without passing through functioning lung tissue. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. shunting. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. 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. 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. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. but the level of carbon dioxide in arterial blood is not elevated even
Gas Exchange and Respiratory Adaptation
gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. alveoli filled with fluid or inflammatory material).
abnorMal gas exchange
Lung disease can lead to severe abnormalities in blood gas composition. impaired oxygen exchange is far more common than impaired carbon dioxide exchange.
When blood perfusing the collapsed. which is usually achieved without difficulty. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. As a result. As noted earlier. The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. Blood leaving an unventilated area of the lung has
. In contrast. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. Because the carbon dioxide–dissociation curve is steep and relatively linear. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure.7
The Respiratory System
though the shunted blood contains more carbon dioxide than arterial blood. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung. and the composite arterial blood carbon dioxide content remains normal. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. The differing effects of shunting on oxygen and carbon dioxide partial pressures are the result of the different configurations of the blood-dissociation curves of the two gases. the content of carbon dioxide is greater than the normal carbon dioxide content. 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. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal.
which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. Inspired air and blood flow normally are distributed uniformly. Thus. In the healthy area of the lung. Overventilated alveoli. In alveoli that are overventilated. reaches a plateau at the normal alveolar partial pressure. and each alveolus receives approximately equal quantities of both. and an increase in blood partial pressure results in a negligible increase in oxygen content. 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. 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. in the arterial blood. however.7
Gas Exchange and Respiratory Adaptation
an oxygen content that is less than the normal content. the amount of carbon dioxide eliminated is increased. a plateau is reached at the
. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and. Mixture of blood from this healthy portion of the lung (with normal oxygen content) and blood from the abnormal area of the lung (with decreased oxygen content) produces a composite arterial oxygen content that is less than the normal level. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. cannot compensate in terms of greater oxygenation for underventilated alveoli because. therefore. alveoli become either overventilated or underventilated in relation to their blood flow. however. The oxygen-dissociation curve. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1.
A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. In disease. and decreased time available for exchange due to increased velocity of flow. Carbon dioxide exchange. which facilitates carbon dioxide exchange. These factors are usually grouped under the broad description of “diffusion limitation. the greater the reduction in blood oxygenation. a reduction in the alveolar partial pressure of oxygen required for diffusion. this distribution can broaden substantially so that individual alveoli can have ratios that markedly deviate from the ratio of 1 to 1. loss of surface area available for diffusion of oxygen.7
The Respiratory System
alveolar partial pressure of oxygen. and increased ventilation will not increase blood oxygen content. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. For oxygen. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange.
. these include increased thickness of the alveolar–capillary membrane. 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. 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. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. A variety of processes can interfere with this orderly exchange.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content.
The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. To recharge the molecule by adding the third phosphate group requires energy derived from
. which set the limit for respiration. where. The precise object of respiration therefore is the supply of oxygen to the mitochondria. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). through the oxidation of foodstuffs such as glucose.7
Gas Exchange and Respiratory Adaptation
interplay of respiration. ATP is degraded to adenosine diphosphate (ADP). the energetic needs of the cells are supplied. circulation. The circulation of the blood links the sites of oxygen use and uptake. For gas exchange that takes place in the lungs. the mitochondria. In antiquity and the medieval period. the heart was regarded as a furnace where the “fire of life” kept the blood boiling. a molecule with only two phosphate bonds. such as the contraction of muscle fibre proteins or the synthesis of protein molecules. and metabolism is the key to the functioning of the respiratory system as a whole. In the process. Each cell maintains a set of furnaces. and MetabolisM
The interplay of respiration. circulation. This involves transport of oxygen from the lung to the tissues by means of the circulation of blood. Modern cell biology has unveiled the truth behind the metaphor. cells set the demand for oxygen uptake and carbon dioxide discharge. 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. whose third phosphate bond can release a quantum of energy to fuel many cell processes.
the number of mitochondria in a cell reflects its capacity for aerobic metabolism. or substrates. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. aerobic metabolism. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. and since each cell must produce its own ATP (it cannot be imported). or even the organism. 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. or fermentation. many cells. Two pathways are available: 1. because the cells maintain only a limited store of highenergy phosphates and of oxygen. which operates in the absence of oxygen. transferred to blood in the lungs. 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. will die. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. It begins with
. anaerobic glycolysis. If oxygen supply is interrupted for a few minutes. whereas they usually have a reasonable supply of substrates in stock. Because oxidative phosphorylation occurs only in mitochondria. or its need for oxygen. and 2. the aerobic metabolic pathway is therefore preferable. In contrast. Oxygen is collected from environmental air. which requires oxygen and involves the mitochondria.7
The Respiratory System
the breakdown of foodstuffs.
It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. which is determined by its content of hemoglobin in the red blood cells. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. the demand for ATP and oxygen increases linearly with work rate. Blood also serves as carrier for both respiratory gases: oxygen. or. This is accompanied by an increased cardiac output. sets the demand for oxygen. transport by blood flow. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. but a highly trained athlete may achieve a more than 20-fold increase. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. and carbon dioxide. and by
. which is achieved by convection or mass flow of air through an ingeniously branched system of airways.5 micrometre) and the surface area of the barrier. more accurately the metabolic rate of the cells. In the most peripheral airways. and discharge to the cells. which is bound to hemoglobin in the red blood cells. which is carried by both plasma and red blood cells and which also serves as a buffer for acid–base balance in blood and tissues. a human consumes about 250 ml of oxygen each minute. Metabolism. With exercise this rate can be increased more than 10-fold in a normal healthy individual. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier. essentially resulting from a higher heart rate.7
Gas Exchange and Respiratory Adaptation
ventilation of the lung. At rest. As more and more muscle cells become engaged in doing work.
with the result that waste products. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. based on observations that oxygen consumption rates differ significantly among species. Knowing precisely what sets the limit is important for understanding respiration as a key vital process. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate.7
The Respiratory System
increased ventilation of the lungs. the athletic species in nature. have an aerobic scope more than twofold greater than that of other animals of the same size. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state.
. the aerobic scope can be increased by training in an individual. such as dogs or horses. The limit to oxidative metabolism is therefore set by some features of the respiratory system. well below interspecies differences. accumulate and limit the duration of work. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. but it is not straightforward. Consequently. Furthermore. this is called adaptive variation. Then. but beyond the aerobic scope they must revert to anaerobic metabolism. a feature called allometric variation. mainly lactic acid. Much has been learned from comparative physiology and morphology. because of the complexity of the system. 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. Muscle can do more work. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. For example. oxygen consumption per unit body mass increases as animals become smaller. from the lung to the mitochondria.
the mitochondria increase in proportion to the augmented aerobic scope.com
Within the aerobic scope the adjustments are caused by functional variation. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system.7
Gas Exchange and Respiratory Adaptation
Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. Shutterstock. cardiac output is augmented by increasing heart rate. the muscle cells make more mitochondria. This difference arises from a phenomenon known as adaptive variation.
. For example. Mitochondria set the demand for oxygen. In training. in all types of variation. If energy (ATP) needs to be produced at a higher rate.
But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. the blood. and the heart can increase in number. mainly the heart. The issue of peripheral versus central limitation is still under debate.7
The Respiratory System
It is thus possible that oxygen consumption is limited at the periphery. the structure of the alveoli in the lungs. both in terms of rate and of the size of the ventricles. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. whereas the mitochondria. 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. which determines the volume of blood that can be pumped with each stroke. that the lung as a gas-exchanging organ has sufficient redundancy that it does not limit aerobic metabolism at the site of oxygen uptake. the levels of hemoglobin in the blood. at the last step of aerobic metabolism. or volume to augment their capacity when energy needs increase. whose capacity to pump blood reaches a limit.
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. In the case of adaptation to high altitudes.
. rate. beyond which oxidative metabolism cannot be increased by training. however. such as in training. It appears. If this proves true. the lung may well constitute the ultimate limit for the respiratory system. the lung lacks this capacity to adapt. But. the blood vessels. In the cases of swimming and diving.
Indigenous mountain species such as the
At high altitudes. such as cattle. Barry C. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen. which heighten the partial pressure of oxygen at all stages. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters.7
Gas Exchange and Respiratory Adaptation
Ascent from sea level to high altitude has well-known effects on respiration. adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. which. both in the ambient air and in the alveolar spaces of the lung. Bishop/National Geographic/Getty Images
. This very fall poses the major respiratory challenge to humans at high altitude. whether undertaken deliberately or not. commences from the time of exposure to high altitudes. Humans and some other mammalian species.
which takes the form of deeper breathing rather than a faster rate at rest. which increases the amount of oxygen transported to the tissues. attached to the division of the carotid arteries on either side of the neck. In addition. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. the size of muscle fibres decreases. from the alveolar spaces in the lung to the mitochondria in the cells. on the other hand. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages. With a prolonged stay at altitude.7
The Respiratory System
llama. the carotid bodies enlarge but become less sensitive to the lack of oxygen. As the oxygen deprivation persists. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. which also shortens the diffusion path of oxygen. 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. Diffusion of oxygen across the alveolar walls into the blood is facilitated. such as 2. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells.3DPG. and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. where oxygen is needed for the ultimate biochemical expression of respiration. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange.
. the tissues develop more blood vessels. exhibit an adaptation that is heritable and has a genetic basis. the carotid bodies. as capillary density is increased. thought to enhance oxygen perfusion of the lung apices. 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. and.
some highlanders lose this acclimatization and develop chronic mountain sickness. They do not develop small muscular blood vessels or an increased blood pressure in the lung. after the Peruvian physician who first described it. A chemodectoma. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen.7
Gas Exchange and Respiratory Adaptation
Indigenous mountain animals like the llama. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. Other physiological changes are also observed.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. After living many years at high altitude. exhibit a set of responses that may be called a “diving reflex. Nevertheless. In contrast to acclimatized humans. Human respiration requires ventilation with air. alpaca. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. 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. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude. these indigenous. including humans. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the
. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. Their hemoglobin has a high oxygen affinity. or benign tumour. all vertebrates. sometimes called Monge disease.
Swimming and Diving
Fluid is not a natural medium for sustaining human life after the fetal stage. and their carotid bodies remain small. This disease is characterized by greater levels of hemoglobin.
the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen. Two factors are involved. which is
. Most hazards result from the environmental pressure of water.7
The Respiratory System
same time that a diver is breathing from an independent gas supply. as sometimes happens in snorkeling. but it cannot provide an equivalent increase in oxygen. The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. and consciousness remains unimpaired. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. the absolute pressure. Unconsciousness may then occur in or under the water. but the oxygen content of the blood concurrently falls to unusually low levels. 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. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. Hyperventilation. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath. Hyperventilation can be dangerous. and this danger is greatly increased if the swimmer descends to depth. many of them unique in human physiology. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. But this apparent advantage introduces additional hazards. When the accumulated carbon dioxide at last forces the swimmer to return to the surface. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. however. At the depth of a diver.
the blood and tissues of the diver. and their subsequent elimination from. often with the formation of bubbles. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. 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. More commonly. rather than cardiac or muscular performance. The increased work of breathing. the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. is one factor. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. the levels of inspired oxygen are
. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia). is the vertical hydrostatic pressure gradient across the body. The other factor. This may be compounded by an increased inspiratory content of carbon dioxide. is the limiting factor for hard physical work underwater. the increased density of the respiratory gases. Alveolar oxygen levels can also be disturbed in diving.7
Gas Exchange and Respiratory Adaptation
approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. acting at any depth. The multiple effects of submersion upon respiration are not easily separated from one another or clearly distinguishable from related effects of pressure upon other bodily systems. and the consequences of the uptake of respiratory gases into. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. Hypoxia may result from failure of the gas supply and may occur without warning.
approximately in proportion to the reciprocal of the square root of the increasing gas density. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels. The use of hydrogen. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. 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. which in a mixture with less than 4 percent oxygen is noncombustible. In mixed-gas diving. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. provides a greater respiratory advantage for deep diving. like an anesthetic.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.2 and 0. At the extreme depths now attainable by humans— some 500 metres (1. inspired oxygen is therefore maintained at a partial pressure somewhere between 0.7
The Respiratory System
increased. has the additional advantage of providing a breathing gas of lesser density. Oxygen in excess can be a poison. it may cause the rapid onset of convulsions. High values of end-tidal carbon dioxide with
. At a partial pressure greater than 1.640 feet) in the sea and more than 680 metres (2. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner.5 bar.5 bar (“surface equivalent value” = 150 percent).
Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. a condition that. Failure to exhale
. The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. in which case more blood will be shifted into the thorax. Also. or it may be effectively greater. the expanding gas may rupture alveolar septa and escape into interstitial spaces. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. places the diver at great risk. And whatever the orientation of the diver in the water. Unless vented. possibly extending into the pericardium or into the neck. Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. which represents the net effect of the external pressures and the effects of chest buoyancy. if it occurs underwater. has proved useful in designing underwater breathing apparatuses. More seriously. This is a major cause of death among divers. resulting in less intrathoracic blood volume.7
Gas Exchange and Respiratory Adaptation
only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity. The concept of a hydrostatic balance point within the chest. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface.
The Respiratory System
during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.6 feet). can result in a sometimes life-threatening condition known as decompression sickness. even from depths as shallow as 2 metres (6. 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.
. 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. Inadequacy of diver decompression. Decompression sickness is caused by the formation of bubbles from gases that were dissolved in the tissues while the diver was at an increased environmental pressure.
bacteria. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. whether of the upper or lower respiratory tract. and molds. resulting in patient isolation. including viruses.
. with this division occurring at the anatomical level of the larynx. infectious diseases. whereas lower respiratory infections include laryngitis. upper respiratory infections include the common cold. Legionnaire disease. Some conditions can cause extensive lung damage. as considered here. and any condition of the bronchi and lungs. These diseases may be caused by a variety of agents. and may be highly contagious. sinusitis. however. pharyngitis. and tuberculosis. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. tracheitis. In most cases. Thus. can be effectively treated with prescription antimicrobial drugs. various types of pneumonia. Examples of severe lower respiratory infections include croup. and tonsillitis.CHAPTER4
INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM
nfectious diseases are among the most common conditions affecting the human respiratory system. requiring patient hospitalization. However. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues.
The common cold is an acute viral infection that starts in the upper respiratory tract. but this is now known to be incorrect. including parainfluenza. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. not from a cold environment. an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. however.7
The Respiratory System
upper respiratory systeM infections
The nasal sinuses. More than 200 agents can cause symptoms of the common cold. pharynx. respiratory syncytial viruses. are the most frequent cause. The feeling was originally believed to have a cause-and-effect relationship with the disease. and reoviruses. usually one to four days. Some of these infections may resolve on their own. In other cases. Rhinoviruses. or drafts. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. and may cause secondary infections in the eyes or middle ears. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. and tonsils are frequently the site of both acute and chronic infections. and the
. The cold is caught from exposure to infected people. with little or no medication. People can carry the virus and communicate it without experiencing any of the symptoms themselves. chilled wet feet. influenza. The viruses start spreading from an infected person before the symptoms appear. Incubation is short. however. sometimes spreads to the lower respiratory structures.
This fluid acts to dilute the virus and clear it from the nose. sore throat. Symptoms may include sneezing. chills. its activities irritate the nose’s cells. Once a virus becomes established on the respiratory surface of the nose. which respond by pouring out streams of clear fluid. Diagnosis of a cold is usually made by medical history alone. The incidence of colds peaks during the autumn. thereby setting up sneezing. headaches. which increases the likelihood of close contact with those persons carrying cold viruses. The usual duration of the illness is about five to seven days. and minor epidemics commonly occur throughout the winter. Symptoms abate as the host’s defenses increase. The sensory organs in the nose are stung by the inflammatory reaction. fatigue. The nasal discharge is the first warning that one has caught a cold. There is usually no fever. and nasal discharge. It may result from the greater amount of time spent indoors.7 Infectious Diseases of the Respiratory System
spread reaches its peak during the symptomatic phase. but the reason for this incidence is unknown. but in the individual the same symptoms tend to recur in succeeding bouts of infection. If the virus penetrates more deeply into the upper respiratory tract. There is no effective antiviral agent available for the common
. Young children can contract between three and eight colds a year. Coughing can be dry or produce amounts of mucus. but lingering cough and postnasal discharge may persist for two weeks or more. Cold symptoms vary from person to person. the clear fluid often changing to a thick. a second method of expelling the virus. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. yellow-green fluid that is full of the debris of dead cells. inflammation of the nose (rhinitis). but it is possible to take a culture for viruses. usually coming into contact with the infectious agents in day care centres or preschools.
Shutterstock. the common cold does not involve a fever.7
The Respiratory System
Usually. fatigue. chills. headaches. and nasal discharge. rhinitis.com 90
. but it can comprise sneezing. sore throat.
administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. and tonsils. the throat reddens. and the tonsils may secrete pus and become swollen. uvula. mycoplasmas. A sore throat may be a symptom of influenza or of other respiratory infections.7 Infectious Diseases of the Respiratory System
cold. or a reaction to certain drugs. The illness can be caused by bacteria. fever. Generally. antibiotics are often effective. For a viral sore throat. Microbial agents producing soreness may remain localized or may spread (by way of lymph channels or the bloodstream) and produce such serious complications as rheumatic fever.
Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). and parasites and by recognized diseases of uncertain causes. 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. which typically subside after one week. In many studies. as are antiseptic gargles.
Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. a result of irritation by foreign objects or fumes. treatment is aimed at relieving symptoms. Therapy consists of treating the symptoms: relieving aches. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. Inflammation usually involves the nasopharynx. viruses. and nasal congestion. In treating nonviral sore throat. fungi. soft palate. Infection by
Sinusitis is acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses (the cavities in the bones that adjoin the nose). and meningitis. and a slight fever. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. Chronic cases caused by irritants in the environment or by
. diphtheria. A number of other infectious diseases may cause pharyngitis. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. Within approximately three days the fever leaves. but the other symptoms may persist for another two to three days. If a diagnosis of streptococcal infection is established by culture. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. is instituted. They cause fever.7
The Respiratory System
Streptococcus bacteria may be a complication arising from a common cold. requiring treatment with antibiotics. and irritability. headache. nausea. Viral pharyngitis infections also occur. usually with penicillin. and the cause of pharyngeal inflammation can be determined by throat culture. swelling of lymph nodes. and sore throat that last for 4 to 14 days. Purulent (pus-producing) sinusitis can occur. headache. a pustulant fluid on the tonsils or discharged from the mouth. extremely sore throat that is felt during swallowing. sometimes in children there are abdominal pain. Lymphatic tissue in the pharynx may also become involved. syphilis. including tuberculosis. Diagnosis is established by a detailed medical history and by physical examination. appropriate antibiotic therapy.
It may also be caused by allergy to agents
. keeping the sinuses clean.7 Infectious Diseases of the Respiratory System
impaired immune systems may require more extended treatment. nasal discharge. Streptococcus pneumoniae. Under normal conditions. Common symptoms include facial pain. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. On physical examination. and fever following previous upper respiratory viral illness. Treatment of acute sinusitis is directed primarily at overcoming the infecting organism by the use of systemic antibiotics such as penicillin and at encouraging drainage of the sinuses by the use of vasoconstricting nose drops and inhalations. and many other penicillin-sensitive anaerobes. including surgery. Staphylococcus aureus. headache. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. The organisms usually involved are Haemophilus influenzae. Chronic sinusitis may follow repeated or neglected attacks of acute sinusitis. persons with sinusitis are usually found to have an elevation in body temperature. Normally the middle ear and the sinuses are sterile. If the infection persists. the pus localized in any individual sinus may have to be removed by means of a minor surgical procedure known as lavage. When ciliary function is damaged. infection can be established. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. Following a common cold. and sinus tenderness. The origin of acute sinus infection is much like that of ear infection. a decrease in ciliary function may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a purulent sinusitis. Streptococcus pyogenes. but the adjacent mouth and nose have a varied bacterial flora.
The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. Pain is not a feature of chronic sinusitis. The treatment includes bed rest until the fever has subsided. with or without heart involvement. More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. The symptoms are sore throat. and ears or downward into the larynx. evidenced by tonsillar enlargement. isolation to protect others from the infection. and sometimes headache. fever. The symptoms of chronic sinusitis are a tendency to colds. The
. virulent bacteria may spread from the infected tonsil to the adjoining tissues. In severe cases endoscopic surgery may be necessary to remove obstructions. sinuses. The infection may extend upward into the nose. and enlarged lymph nodes on both sides of the neck. If antibiotic therapy or repeated lavage do not alleviate the condition. loss of smell. malaise. Locally. repeated or persistent sore throat. usually hemolytic streptococci or viruses. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. Repeated acute infections may cause chronic inflammation of the tonsils. trachea. difficulty in swallowing. such as fungi or pollen.
Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. resulting in a peritonsillar abscess. and swollen lymph nodes in the neck. purulent nasal discharge. and bronchi. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions.7
The Respiratory System
in the environment. and warm throat irrigations or gargles with a mild antiseptic solution. obstructed breathing. The infection lasts about five days.
and trench mouth may also produce acute tonsillitis. pneumonia. Usually the mucous membrane lining the larynx is the site of prime infection. which is a major cause of lung disease globally. Scarlet fever. In diphtheria the tonsils are covered with a thick. It becomes swollen and filled with blood. Laryngitis is classified as simple. with a grayish membrane that wipes off readily. or sulfur dioxide can also cause severe inflammation. Likewise. and contains many
. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. steam. diphtheritic. Thus. tuberculous. involving long-term antimicrobial therapy. or syphilitic. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. in order to prevent potentially disabling damage to lung tissue. secretes a thick mucous substance. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. the infectious disease tuberculosis.7 Infectious Diseases of the Respiratory System
treatment in this case is surgical removal (tonsillectomy). adherent membrane. Nonbacterial agents such as chlorine gas. diphtheria.
lower respiratory systeM infections
Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. in trench mouth. whitish. is associated with a high rate of death in infants and the elderly. For example.
Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. Simple laryngitis is usually associated with the common cold or similar infections.
or overuse of the vocal cords. alcoholism. sores or mucous patches can form. The bacteria die after infecting the tissue. small lumps of tissue that project from the surface. they may consolidate at the vocal cords and cause an obstruction there. becomes swollen and infected by influenza viruses. When looser portions of this false membrane become dislodged from part of the larynx. leaving ulcers on the surface. fibrin (blood clotting protein). tissue destruction is followed by healing and scar formation. Chronic laryngitis is produced by excessive smoking. In the second stage of syphilis. As the disease advances to the third stage. the larynx can become obstructed. The wall of the larynx may thicken and become inflamed. Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. and produce a permanent hoarseness of the voice.7
The Respiratory System
inflammatory cells. and suffocation may result. shorten the vocal cords. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. The mucous membrane becomes dry and covered with polyps. which closes the larynx during swallowing. It may cause a membrane of white blood cells. Most conditions that affect the trachea are bacterial or
Tracheitis is an inflammation and infection of the trachea. When the epiglottis. A similar type of membrane covering can occur in streptococcal infections. and diseased skin cells to attach to and infiltrate the surface mucous membrane. Tubercular nodule-like growths are formed in the larynx tissue. Syphilitic laryngitis is one of the many complications of syphilis. The scars can distort the larynx. There may be eventual destruction of the epiglottis and laryngeal cartilage.
The mucous glands may become swollen. and the walls thicken because of an increase in elastic and muscle fibres. form in the mucous membrane. Common bacterial causes of acute infections are pneumococci. Irritants such as heavy smoking and alcoholism may invite infections. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. Acute infections occur suddenly and usually subside quickly. In smallpox. although irritants like chlorine gas. and syphilis all afflict the trachea. and small polyplike formations occasionally grow. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. but the trachea may also be attacked. sulfur dioxide. Chronic infections recur over a number of years and cause progressive degeneration of tissue. such as those that occur on the external skin. smallpox. tuberculosis. hemorrhages. The walls of the trachea during chronic infection contain an excess of white blood cells. they do not cause significant damage to the tissue unless they become chronic. Generally. and swelling of the mucous membrane lining the trachea. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. fatigue. Neisseria organisms. pustules and ulcers. Intense blood congestion. and staphylococci. streptococci. Degenerated tissue is eventually replaced by a fibrous scar tissue. Blood vessels increase in number. Typhoid causes swelling and ulceration in the lymph tissue. Infections may last for a week or two and then pass. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. Diphtheria usually involves the upper mouth and throat. The infections produce fever. Syphilis forms lesions that erode the
. Diphtheria.7 Infectious Diseases of the Respiratory System
viral infections. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. and degeneration of the tracheal tissue can occur.
and can cause thickening and stiffening of the spaces between the cartilage. Such infections are most prevalent among children younger than age three. Generally. and they strike most frequently in late fall and winter. and difficult breathing. making it necessary for the patient to sit and lean
. is a more serious condition that is often caused by Haemophilus influenzae type B. inflammation occurs around the bronchial tree. In cases of severe airway obstruction. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. Because of the marked swelling of the epiglottis. also called epiglottitis. the most frequent being those with the parainfluenza and influenza viruses.
Croup is an acute respiratory illness of young children that is characterized by a harsh cough. there is obstruction at the opening of the trachea. It is characterized by marked swelling of the epiglottis. 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. Epinephrine and corticosteroids have also been used to reduce swelling of the airway. Bacterial croup. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. It is most often caused by an infection of the airway in the region of the larynx and trachea. The onset is usually abrupt. hoarseness. spasms of the laryngeal muscles.7
The Respiratory System
tissue. with high fever and breathing difficulties. Some cases result from allergy or physical irritation of these tissues. hospitalization may be necessary. In some cases. The symptoms are caused by inflammation of the laryngeal membranes. or inflammation around the trachea.
Acute bronchitis can also be caused by bacteria such as Streptococcus. It is most frequently caused by viruses responsible for upper respiratory infections. or organic solvents. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. 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. Therefore.
. Patients are given antibiotics. resulting usually in a relatively brief disease called acute infectious bronchitis. preferably by inserting a tube down the windpipe. organisms do enter the airways and initiate a sudden and rapid attack. Under ordinary circumstances. which generally relieve the inflammation within 24 to 72 hours. In addition. Under certain circumstances. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. influenzae. Children with epiglottitis require prompt medical attention. it is often part of the common cold and is a common sequel to influenza.
Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). particularly in people who have underlying chronic lung disease. through which air passes into the lungs. whooping cough. and measles. Epiglottitis generally strikes children between ages three and seven. The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. An artificial airway must be opened. ammonia. however.7 Infectious Diseases of the Respiratory System
forward to maximize the airflow. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks.
and expectorants will usually relieve the symptoms. This pattern of occurrence has only recently been recognized. particularly in children between ages one and two. and particularly in infections with respiratory syncytial virus. an acute bronchiolitis episode is followed by a chronic obliterative condition. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal.7
The Respiratory System
Treatment of acute bronchitis is largely symptomatic and of limited benefit. with complete healing in all but a very small percentage of cases. Bronchiolitis probably occurs to some extent in acute viral disorders. acute exacerbations of infection are associated with further damage to small airways. but it normally clears spontaneously. In some cases the inflammation may be severe enough to threaten life. which results in protracted and often permanent damage to the bronchial mucosa. In isolated cases. In addition to patients acutely exposed to gases. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. is a long-standing. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability. In adults. or this may develop slowly over time. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. Another form of bronchitis. in whom such a syndrome may follow the acute exposure.
. discussed in a later chapter. repetitive condition. called chronic bronchitis.
Bronchiolitis refers to inflammation of the small airways. though there is little doubt that in most patients with chronic bronchitis. bronchodilators. Steam inhalation.
Symptomatic recovery may mask incomplete resolution of the inflammation. known as a respiratory bronchiolitis. which may occur from inhaling gas in silos. when welding in enclosed spaces such as boilers. A chest radiograph shows patchy inflammatory change. when the victim develops a short cough and progressive shortness of breath. but a short cough and progressive shortness of breath may not be evident for hours.7 Infectious Diseases of the Respiratory System
Welding in enclosed spaces often results in exposure to oxides of nitrogen. Monty Rakusen/Cultura/Getty Images
Exposure to oxides of nitrogen. An inflammation around the small airways.
. or in fires involving plastic materials. is characteristically not followed by acute symptoms. These develop some hours later. after blasting underground. is believed to be the earliest change that occurs in the lung in cigarette smokers. and the lesion is an acute bronchiolitis.
together with varying degrees of soreness in the head and abdomen. and a generalized feeling of weakness and pain in the muscles. It is not known whether those who develop this change (after possibly only a few years of smoking) are or are not at special risk of developing the long-term changes of chronic bronchitis and emphysema. fatigue. The temperature rises rapidly to 38–40 °C (101–104 °F). after which the onset of symptoms is abrupt. As the virus particles gain entrance to the body. bronchial tubes. and trachea. The inflammation is probably reversible if smoking is discontinued. also known simply as the flu (or grippe). chills.7
The Respiratory System
although it does not lead to symptoms of disease at that stage. by such means as inhalation of infected droplets resulting from coughing and sneezing.
Influenza. though the highest incidence of the disease is among children and young adults. Symptoms associated with respiratory tract
. The flu may affect individuals of all ages. and it is generally more frequent during the colder months of the year. A diffuse headache and severe muscular aches throughout the body are experienced. and the person begins to recover. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. In three to four days the temperature begins to fall. and muscle aches. is an acute viral infection of the upper or lower respiratory tract that is marked by fever. with sudden and distinct chills. The incubation period of the disease is one to two days. often accompanied by irritation or a sense of rawness in the throat. Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract.
In order to prevent humaninfecting bird flu viruses from mutating into more
. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). such as coughing and nasal discharge. Death may occur. viral resistance to these agents has been observed. Protection from one vaccination seldom lasts more than a year. routine immunization in healthy people is also recommended. Other than this. become more prominent and may be accompanied by lingering feelings of weakness. the standard treatment remains bed rest. However. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. as well as a strain of virus known as influenza type B. ingestion of fluids. a very serious illness. thereby reducing their effectiveness. A newer category of drugs. It is recommended that children and teenagers with the flu not be given aspirin. However.7 Infectious Diseases of the Respiratory System
infection. usually among older people already weakened by other debilitating disorders. and yearly vaccination may be recommended. particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. these drugs inhibit influenza A. was introduced in the late 1990s. 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. the neuraminidase inhibitors. and is caused in most of those cases by complications such as pneumonia or bronchitis. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. These viruses are produced in chick embryos and rendered noninfective. and the use of analgesics to control fever. as treatment of viral infections with aspirin is associated with Reye syndrome.
If taken within 30 hours of
. zanamivir decreases the release of virus from infected cells. increases the formation of viral aggregates. Through the inhibition of neuraminidase. a glycoprotein on the surface of influenza viruses.7
The Respiratory System
dangerous subtypes. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus. Oseltamivir can be given orally. increases the formation of viral aggregates. Zanamivir is given by inhalation only. has developed resistance to oseltamivir. the drug decreases the release of virus from infected cells. Inc. public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. Oseltamivir is effective when administered within two days of symptom onset. known as H1N1. There is evidence that the most common subtype of influenza type A virus. and decreases the spread of the virus through the body. 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.S. Zanamivir (Relenza) Zanamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U.based pharmaceutical company Hoffman–La Roche. Oseltamivir is marketed as Tamiflu by the U. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors.S. and decreases the spread of the virus through the body.
Centers for Disease Control and Prevention (CDC) (Image Number: 2121)
.7 Infectious Diseases of the Respiratory System
the onset of influenza. highly communicable respiratory disease. Whooping cough is caused by the bacterium Bordatella pertussis. zanamivir can shorten the duration of the illness. is an acute. sticky mucus and often with vomiting. isolated and coloured with Gram stain. the causative agent of whooping cough.” The coughing ends with the expulsion of clear. when taken once daily for 10 to 28 days.
Bordetella pertussis. Zanamivir. can prevent influenza infection in some adults and children.
Whooping cough. or pertussis. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. or “whoop.
the name pertussis (Latin: “intensive cough”) was introduced in England. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. and still later Bordetella pertussis. Beginning its onset after an incubation period of approximately one week. During the convalescent stage there is gradual recovery. paroxysmal. In 1906 at the Pasteur Institute. and pertussis) vaccine. it confers active immunity against whooping cough to children. and a low-grade fever. red eyes. Now included in the DPT (diphtheria. Immunization is routinely begun at two months of age and requires five shots for maximum
. there is a repetitive series of coughs that are exhausting and often result in vomiting. undoubtedly it had existed for a long time before that. ear infections. The infected person may appear blue. with bulging eyes. and be dazed and apathetic. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. and occasionally convulsions and indications of brain damage.7
The Respiratory System
Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. the illness progresses through three stages—catarrhal. In the paroxysmal state. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. but the periods between coughing paroxysms are comfortable. variable in duration but commonly lasting four to six weeks. with a short dry cough that is worse at night. later Haemophilus pertussis. and convalescent—which together last six to eight weeks. The disease was first adequately described in 1578. About 100 years later. Complications of whooping cough include pneumonia. Catarrhal symptoms are those of a cold. It was first called the Bordet-Gengou bacillus. slowed or stopped breathing. Whooping cough is worldwide in distribution and among the most acute infections of children. tetanus.
Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. pigeons. the causative agent was revealed. because the disease is much less severe when it occurs in older children. Sedatives may be administered to induce rest and sleep. Later vaccinations are in any case thought to be unnecessary. turkeys. and another booster is given when the child is between four and six years old. parrots and parakeets (family Psittacidae. ducks. Treatment includes erythromycin. attributed to contact with imported parrots.
Psittacosis. and the United States. an antibiotic that may help to shorten the duration of illness and the period of communicability. The infection has been found in about 70 different species of birds. from which the disease is named). A booster dose of pertussis vaccine should be given between 15 and 18 months of age. and sometimes the use of an oxygen tent is required to ease breathing. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. although a thorough study of the disease was not made until 1929– 30. especially if they have been vaccinated in infancy. also known as ornithosis (or parrot fever).7 Infectious Diseases of the Respiratory System
protection. The association between the human disease and sick parrots was first recognized in Europe in 1879. when severe outbreaks. During the investigations conducted in Germany. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. England. Strict regulations followed concerning
. and geese are the principal sources of human infection. occurred in 12 countries of Europe and America.
Although viral pneumonia does occur. Many organisms. head and body aches. the case fatality rate was approximately 20 percent.
Pneumonia is an inflammation and solidification of the lung tissue as a result of infection. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. Other symptoms include chills. Infected turkeys. or irradiation. Fungal pneumonia can develop very rapidly and may be fatal. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. and convalescence often is protracted.7
The Respiratory System
importation of psittacine birds. Psittacosis usually causes only mild symptoms of illness in birds. but the most common causes are bacteria. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. ducks. viruses more commonly play a part in weakening the lung. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. have reduced resistance to
. and an elevated respiratory rate. Before modern antibiotic drugs were available. because of impaired immunity. but in humans it can be fatal if untreated. in particular species of Streptococcus and Mycoplasma. 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 it usually occurs in hospitalized persons who. can cause pneumonia. In humans psittacosis may cause high fever and pneumonia. but penicillin and the tetracycline drugs reduced this figure almost to zero. including viruses and fungi. weakness. inhalation of foreign particles. thus inviting secondary pneumonia caused by bacteria.
cough. Contaminated dusts. In some cases. The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. to agents such as mold. Sputum discharge may contain flecks of blood. Bacterial Pneumonia Streptococcal pneumonia. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. As the disease progresses. coughing becomes the major symptom.. Treatment is with specific antibiotics and supportive care. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the
. particularly in elderly people and young children. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. when inhaled by previously healthy individuals. These fluids provide an environment in which the bacteria flourish. can sometimes cause fungal lung diseases. caused by Streptococcus pneumoniae. chest pain.g. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing.7 Infectious Diseases of the Respiratory System
infection. and difficulty in breathing. humidifiers. is the single most common form of pneumonia. and recovery generally occurs in a few weeks. and it is sometimes fatal. or allergic response. the illness may become very severe. Pneumonia can also occur as a hypersensitivity. however. especially in hospitalized patients. and animal excreta or to chemical or physical injury (e. smoke inhalation). Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract.
parainfluenza. Symptoms of
. caused by Mycoplasma pneumoniae. Mycoplasmal pneumonia. 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. few cases beyond age 50 are seen. although it has little ability to infect the lungs of healthy persons. Another bacterium. Other bacterial pneumonias include Legionnaire disease. M. or nerves. or institutions. Usually the organism does not invade the membrane that surrounds the lungs. an atypical infectious form. which leads to the further release of pneumolysin. it does not invade the deeper tissues—muscle fibres. but it does sometimes inflame the bronchi and alveoli. Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. Most outbreaks of this disease are confined to families. small neighbourhoods. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. causing bleeding into the air spaces. usually affects children and young adults. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. an extremely small organism.7
The Respiratory System
lungs. and influenza viruses. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. Klebsiella pneumoniae. elastic fibres. although epidemics can occur. caused by Legionella pneumophilia.
the prognosis is excellent. all of which may subside in a day if there is no further exposure. AIDS. Other fungi found in barley. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. Tuberculosis should always be considered a possibility in any patient with pneumonia. parakeets. These pneumonias may occur following exposure to moldy hay or sugarcane. all of which contain the fungus Actinomyces. decreased appetite. room humidifiers. In general. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. maple logs.7 Infectious Diseases of the Respiratory System
these pneumonias include runny nose. and doves may develop manifestations of hypersensitivity pneumonia. cough. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. Diagnosis is established by physical examination and chest X-rays. people exposed to rats. old sheds or barns. or other chronic diseases. gerbils. In addition. and wood pulp may cause similar illnesses. and malaise. and low-grade fever. usually followed by respiratory congestion and cough. headache. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. pigeons. muscle pain. shortness of breath. or dust storms. and air-conditioning ducts. and skin testing is included in the initial examination of patients with lung problems. these patients experience fever with chills. particularly if the patient was recently exposed to excavations. Nonbacterial pneumonia is treated primarily with supportive care. Initially. backyard swimming pools. A more insidious form of hypersensitivity pneumonia is
Such infections are a major cause of illness in these patients. Treatment consists of removing the patient from the offending environment. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. and cough. less often. Ordinarily no treatment is necessary. Oil that is being swallowed may be breathed into the respiratory tract. Diagnosis is established by medical history. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. and specific laboratory tests. it had been known that if the immune system was compromised by immunosuppressive drugs (given.) Recovery is usual unless too great an area of lung tissue is involved. capable of causing invasive pneumonic lesions in the setting of reduced immunity. and may prove fatal. Infections with fungi such as
. physical examination. fever. before organ transplantation to reduce the rate of rejection). Scar tissue forms as a result of the presence of the oil. for example. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. it may come from the body itself when the lung is physically injured. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. This type of disease. are difficult to treat. known as lipoid pneumonia. bed rest. weight loss. and supportive care. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections.7
The Respiratory System
associated with persistent malaise. Pneumonia in Immunocompromised Persons For some years prior to 1980. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. or.
Coughing. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. the exact source of outbreaks is often difficult to determine. Potable water and drainage systems are suspect. as is water at construction sites. often accompanied by chills.7 Infectious Diseases of the Respiratory System
Candida also occur. a U. at a Philadelphia hotel where 182 Legionnaires contracted the disease. The largest known outbreak of Legionnaire disease. Although it is fairly well documented that the disease is rarely spread through person-to-person contact. pneumophila in droplets into the surrounding atmosphere. shortness of breath. pleurisy-like pain. followed by high fever. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease. in 2001. 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. Typically. confirmed in more than 300 people. 29 of them fatally. the first symptoms of Legionnaire disease are general malaise and headache.
Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. Spain. and occasionally some mental confusion is present. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion.
. and abdominal distress are common. military veterans’ organization. occurred in Murcia. but not uniformly.S. Although healthy individuals can contract Legionnaire disease.
Indeed. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. at which time improved health and hygiene brought about a steady decline in its mortality rates. In most forms of the disease. Pontiac fever. pneumophila enters the lungs. L. and death. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. this cycle of infection can lead to severe pneumonia. headache. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication.7
The Respiratory System
Once in the body.” as it was then known. Since the
. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. represents a milder form of Legionella infection. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. L. Eventually. coma. and muscle pain. “consumption. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis. However.
Tuberculosis is an infectious disease that is caused by the tubercle bacillus. Blood vessels also can be eroded by the advancing disease. causing the infected person to cough up bright red blood. the bacillus spreads slowly and widely in the lungs. Mycobacterium tuberculosis. Treatment for Legionnaire disease is with antibiotics. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs. the macrophage dies and bursts open. In some cases. pneumophila. an influenza-like illness characterized by fever. During the 18th and 19th centuries.
an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. 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. but in areas with poor hygiene standards. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. antibiotic drugs have reduced the span of treatment to months instead of years. the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the
. it continues to be a fatal disease continually complicated by drug-resistant strains. Today. Fox Photos/Hulton Archive/Getty Images
1940s.7 Infectious Diseases of the Respiratory System
Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries. In addition. in less-developed countries where population is dense and hygienic standards poor. tuberculosis remains a major fatal disease.
Individual tubercles are microscopic in size. Minute droplets ejected by sneezing. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. nodular tubercles. A tubercle usually consists of a centre of dead cells and tissues. The Course of Tuberculosis The tubercle bacillus is a small. are surrounded by immune cells. and finally are sealed up in hard. it can survive for months in a state of dryness and can also resist the action of mild disinfectants. the primary infection often heals without causing symptoms. In this condition. There the bacilli become trapped in the tissues of the body. sometimes involving the use of five different agents. coughing. Infections with these strains are often difficult to treat and require the use of combination drug therapies.7
The Respiratory System
rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. A skin test taken at any later time may reveal the earlier infection and the immunity. In otherwise healthy children and adults. sometimes called latent
. and a small scar in the lung may be visible by X-ray. but most of the visible manifestations of tuberculosis. are conglomerations of tubercles. in which can be found many bacilli. from barely visible nodules to large tuberculous masses. The bacilli are quickly sequestered in the tissues. and the infected person acquires a lifelong immunity to the disease. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells. cheeselike (caseous) in appearance. rod-shaped bacterium that is extremely hardy. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air.
before the advent of specific drugs. a highly infectious stage of the disease. releasing viable bacilli into the bloodstream. sometimes after periods of time that can reach 40 years or more. however.7 Infectious Diseases of the Respiratory System
tuberculosis. intestines. In fact. An infection of the meninges that cover the brain causes tuberculous meningitis. this disease was always fatal. an alarming symptom. These symptoms do not subside. once the bacilli enter the bloodstream. kidneys. the patient may have chest pain from pleurisy. with lack of energy. causing a pleural effusion. and there may be blood in the sputum. or collection of fluid outside the lung. Eventually. This lesion may erode a neighbouring bronchus or blood vessel. genital organs. In some cases the infection may break into the pleural space between the lung and the chest wall. the affected person is not contagious. and persistent cough. Fever develops. Tubercular lesions
. The onset of pulmonary tuberculosis is usually insidious. causing miliary tuberculosis. This causes a condition known as pulmonary tuberculosis. the elderly. In the lung. the primary infection may spread through the body. In some cases. for example). the cough increases. skin. including the lymph nodes. Particularly among infants. though most affected people now recover. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. bones and joints. they can travel to almost any organ of the body. and immunocompromised adults (organ transplant recipients or AIDS patients. and the general health of the patient deteriorates. a highly fatal form if not adequately treated. weight loss. most commonly in the upper portion of one or both lungs. and bladder. usually with drenching night sweats. From the blood the bacilli create new tissue infections elsewhere in the body. the original tubercles break down. causing the patient to cough up blood (hemoptysis).
and M. and it is also excreted in milk. atypical mycobacteria. along with the systematic identification and destruction of infected cattle. M. finally eroding through the skin as a chronic discharging ulcer. bovis readily infects humans. M. The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. often resulting in a hunchback deformity. bovis may spread into the bloodstream and reach any part of the body. where it causes destruction of tissue and eventually gross deformity. ulcerans. has led to the disappearance of bovine tuberculosis in humans in many countries. however. Pasteurization of milk kills tubercle bacilli. where it causes caseation of the node tissue (a condition formerly known as scrofula). is characterized by softening and collapse of the vertebrae. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. and scarring. bovis.7
The Respiratory System
may spread extensively in the lung. Other Mycobacterial Infections Another species of bacteria. This group includes such Mycobacterium species as M. and this. The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. kansasii. It shows.
. a great preference for bones and joints. is the cause of bovine tuberculosis. M. The node swells under the skin of the neck. and mycobacteria other than tuberculosis (MOTT). M. Tuberculosis of the spine. bovis is transmitted among cattle and some wild animals through the respiratory route. marinum. cavities. M. The amount of lung tissue available for the exchange of gases in respiration decreases. causing large areas of destruction. M. aviumintracellulare). avium (or M. If the milk is ingested raw. From the gastrointestinal tract. or Pott disease.
it causes a local reaction. its use in young children in particular has helped to control infection in the developing world. The main hope of ultimate control.7 Infectious Diseases of the Respiratory System
These bacilli have long been known to infect animals and humans. If bacilli are present. in the urine. or in the cerebrospinal fluid. possibly in isolation until they are noninfectious. but the prognosis is usually poor owing to the AIDS patient’s overall condition. and other organs only in people whose immune systems have been weakened. is composed of specially weakened tubercle bacilli. Among AIDS patients. however. In many developed countries. It has been widely used in some countries with success. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment. and this means treating infectious patients quickly. lies in preventing exposure to infection. A vaccine. tuberculosis. tuberculosis for several years. Injected into the skin. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. An X-ray of the lungs may show typical shadows caused by tubercular nodules or lesions. in which a sputum specimen is smeared onto a slide. in gastric washings. and examined under a microscope. The primary method used to confirm the presence of bacilli is a sputum smear. but they cause dangerous illnesses of the lungs. known as BCG vaccine. which confers some immunity to infection by M. atypical mycobacterial illnesses are common complications of HIV infection. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. Treatment is attempted with various drugs. stained with a compound that penetrates the organism’s cell wall. lymph nodes. individuals at risk
surgery is rarely needed. As a result. making the patient sick again.
. bacilli will become resistant and multiply. but complete cure requires continuous treatment for another four to nine months. and pyrazinamide.7
The Respiratory System
for tuberculosis. ethambutol. Historically. often years. such as health care workers. with early drug treatment. These drugs may be given daily or two times per week. If a patient does not continue treatment for the required time or is treated with only one drug. If subsequent treatment is also incomplete. The patient is usually made noninfectious quite quickly. the surviving bacilli will become resistant to several drugs. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. rifampicin. These drugs are often used in various combinations with other agents. 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. treatment of tuberculosis consisted of long periods. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. in order to avoid the development of drug-resistant bacilli. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. of bed rest and surgical removal of useless lung tissue. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. or rifapentine. such as ethambutol. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. pyrazinamide. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). Today.
the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. Aggressive treatment using five different drugs. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. amikacin. such as kanamycin.
. In addition. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. In 1995. 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. MDR TB is treatable but is extremely difficult to cure.7 Infectious Diseases of the Respiratory System
Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. Instead of taking daily medication on their own. it has proved successful in controlling tuberculosis. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. in part to prevent the development and spread of MDR TB. or capreomycin. Although some patients consider DOT invasive.
they are by no means rigid. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. emphysema. diseases of the larynx. and nasopharynx are all susceptible to disease.CHAPTER5
DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM
here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. bronchial tree. and disease in one region frequently leads to involvement of other parts. and in many cases therapy may include not only the administration of medications but invasive surgery as well. trachea. and diseases of the mediastinum and diaphragm. palate. Although these divisions provide a general outline of the ways in which diseases may affect the lung. and cystic fibrosis. It is common for more than one part of the system to be involved in any particular disease process. Treatment for this group of conditions is similarly varied. sinuses. there are diseases of the upper airways. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect.
diseases of the upper airway
The nose. Conditions affecting these tissues may
. diseases of the pleura. Important examples of diseases and disorders of the respiratory system include sleep apnea. The causes of the various diseases and disorders are diverse. Thus. ranging from inherited genetic mutations to smoking to trauma. and lungs.
hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords.e.. loud interrupted snoring can indicate sleep apnea.
Snoring is a rough. a potentially life-threatening condition.7
Diseases and Disorders of the Respiratory System
result from a number of different causes. which necessitates breathing through the mouth. cancer).istockphoto. © www . Snoring is more common in the elderly because the loss of tone in the oropharyngeal
Although snoring bears the brunt of many jokes. such as congenital structural abnormalities or malignant neoplastic changes (i.com / Stephanie Horrocks 123
. Such cancers are typically more common in smokers than in nonsmokers. It is often associated with obstruction of the nasal passages.
Whatever the cause. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. which is the most common form and involves the collapse of tissues of the upper airway. or body-mass index. Thus.” There are three types of sleep apnea: obstructive.
Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. and it occurs most often in obese persons. In obstructive sleep apnea (OSA). The word apnea is derived from the Greek apnoia. the condition has a strong association with certain measures of obesity. body weight. Obstructive sleep apnea is most often caused by excessive fat in the neck area. which involves characteristics of both obstructive and central apneas. airway collapse is eventually terminated by a brief awakening. such as neck size. and mixed. Children’s snoring usually results from enlarged tonsils or adenoids. at which point the airway reopens and the person resumes breathing. It is also more common in men than in women. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. In addition. a common and potentially lifethreatening condition that generally requires treatment. meaning “without breath. 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. Loud interrupted snoring is a regular feature of sleep apnea. with the likelihood of OSA increasing
The Respiratory System
musculature promotes vibration of the soft palate and pharynx. central. In men shirt size is a useful predictor.
with many patients describing sleep as unrefreshing. worsen short-term memory.5 inches). which can be resolved only by weight loss or treatment of underlying conditions. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. Treatment typically involves continuous positive airway pressure (CPAP). The condition is also more common in patients with a set-back chin (retrognathia). it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. The risk returns to normal after treatment.7 Diseases and Disorders of the Respiratory System
with a collar greater than about 42 cm (16. However. The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. it is less certain that these diseases are caused by OSA. it does prevent airway collapse and thus relieves daytime sleepiness.
. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents. such as hypothyroidism or tonsillar enlargement. Other causes of the condition include medical disorders. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. Although CPAP does not treat the condition itself. The most common symptom of OSA is sleepiness. with the resumption of breathing usually described as a gasp or a snort. though surgery is seldom recommended. hypertension.and sevenfold. and insulin resistance. which uses a mask (facial or nasal) during sleep to blow air into the upper airway. and increase irritability. and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. Sleep disturbance may cause difficulty concentrating. the magnitude of the increased risk is the subject of some debate but is thought to be between three. including ischemic heart disease.
is a complex of respiratory and circulatory symptoms associated with extreme obesity.
diseases of the pleura
The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. Finally. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers. who showed some of the same traits. The pleural membranes of the
. oxygen in the blood is also significantly reduced. Individuals who have pickwickian syndrome often complain of slow thinking. The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. excessive fluid accumulates throughout the body (peripheral edema). leading to respiratory acidosis. In more severe instances. The elevated pressure stresses the right ventricle of the heart. levels of carbon dioxide in the blood increase. drowsiness.7
The Respiratory System
Pickwickian syndrome. especially beneath the skin of the lower legs. (By some definitions. and fatigue. an extremely obese person would exceed the optimum weight by a much larger percentage. to be obese is to exceed one’s ideal weight by 20 percent or more.) This condition often occurs in association with sleep apnea. thus increasing pressure in the vessels that supply the lungs. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level. also known as obesity hypoventilation syndrome. ultimately causing right heart failure. Low blood oxygen causes the small blood vessels entering the lungs to constrict. Because of inadequate removal of carbon dioxide by the lungs. in the space known as the pleural cavity.
This causes spontaneous pneumothorax. Pleurisy is commonly caused by infection in the underlying lung and.
Pleural Effusion and Thoracic Empyema
Pleural effusion. a cancer of the pleura. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. There are many causes of
. In wet pleurisy. fluids produced by the inflamed tissues accumulate within the pleural cavity. enabling air to enter the pleural cavity. including tissues of the neck and head. and treatment of the underlying disease. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. Treatment of pleurisy includes pain relief. may occur many years after inhalation of asbestos fibres.7 Diseases and Disorders of the Respiratory System
lungs are also vulnerable to perforation and spontaneous rupture. rarely. Pleurisy may be characterized as dry or wet. by diffuse inflammatory conditions such as lupus erythematosus. or hydrothorax. is an inflammation of the pleura. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. Mesothelioma.
Pleurisy. little or no abnormal fluid accumulates in the pleural cavity. also called pleuritis. is an accumulation of watery fluid in the pleural cavity. pleurisy can be very painful. In dry pleurisy. fluid evacuation. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. the membranes that line the thoracic cavity and fold in to cover the lungs. a partial or occasionally complete collapse of the lung. Because the pleura is well supplied with nerves.
Treatment is directed at drainage of small amounts of pus through
. and the presence of fluid as ascertained by a chest X-ray.e. When the bronchial tree is involved in the infection. 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. including pneumonia. Large pleural effusions can cause disabling shortness of breath. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. The accumulation of pus in the pleural cavity is known as thoracic empyema. and fluid that seeps from the lungs places additional stress on the dysfunctioning heart.7
The Respiratory System
pleural effusion. The presence of both air and pus inside the pleural cavity is known as pneumothorax. infection within the pleural cavity. This condition is often the result of a microbial. tissue adhesions obliterate the pleural space. As the inflammation heals.. and bleomycin. or pyothorax. If symptoms of pleural effusion develop. such as malignant disease of the pleura (i. tuberculosis. mesothelioma). a tube is inserted through the chest wall into the pleural space to drain the fluid. coughing. air may get into the pleural cavity. Under certain conditions. It may also be caused by a lung abscess or some forms of tuberculosis. shortness of breath. doxycycline. and weight loss. usually bacterial. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. and the spread of a malignant tumour from a distant site to the pleural surface. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. Thoracic empyema may be characterized by fever.
air and pressure accumulate within the chest. and tension pneumothorax. When the lung on the affected side of the chest collapses. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. In contrast to traumatic pneumothorax and spontaneous pneumothorax. spontaneous pneumothorax. Spontaneous pneumothorax is the passage of air into the pleural sac from an abnormal connection created between the pleura and the bronchial system as a result of bullous emphysema or some other lung disease. or thoracoscopy (closed-lung biopsy).7 Diseases and Disorders of the Respiratory System
a needle or larger amounts through a drainage tube. There are three major types of pneumothorax: traumatic pneumothorax. Antibiotics are used to treat the underlying infection. or medical procedures. lung infection. blood
. causing it to expand and thus compress the underlying lung. such as high-pressure mechanical ventilation. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. which may then collapse. after which air is sucked through the opening and into the pleural sac.
Pneumothorax is a condition in which air accumulates in the pleural space. chest compression during cardiopulmonary resuscitation (CPR). gunshot) or other injuries to the chest wall. with each breath the patient inhales. As a result. Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. in tension pneumothorax air that becomes trapped in the pleural space cannot escape. the heart.
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.7
The Respiratory System
vessels. In fact. of the toes) may occur. others may require surgery to prevent recurrences. thereby compressing the other lung. It consists of a dilatation of major bronchi. occasionally. This procedure allows air to escape from the chest cavity. Whereas several diseases of the bronchi and lungs. Most pneumothoraxes can be treated by inserting a tube through the chest wall. which enables the lung to reexpand. a catheter connected to a vacuum system is required to re-expand the lung. This leads to decreases in blood pressure. While small pneumothoraxes may resolve spontaneously. and airways are pushed to the centre of the chest. may be present in childhood. and breathing that in turn may lead to shock and death. and excess sputum production and episodes of chest infection are common. The disease may also develop as a consequence of airway obstruction or of undetected (and
. possibly after a severe attack of pneumonia. clubbing (swelling of the fingertips and.
diseases of the bronchi and lungs
Diseases of the bronchi and lungs are often associated with significant impairments in respiration.
Bronchiectasis is believed to usually begin in childhood. consciousness. many of these conditions are associated with irreversible lung damage. In some cases. including bronchiectasis and cystic fibrosis. The bronchi become chronically infected.
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. many of whom. In some countries chronic bronchitis is caused by daily
. in addition to others. particularly in areas of uncontrolled coal burning. These therapies. now reach adult life. medications to dilate the airways and to relieve pain. For example. of which the most important is the familial disease cystic fibrosis. have helped control pulmonary infections and have markedly improved survival in affected persons.” without serious implications. Bronchiectasis may also develop as a consequence of inherited conditions. Management of the condition includes antibiotics to fight lung infections. who would formerly have died in childhood. significant quantities of mucus are coughed up in the morning. due to an increase in size and number of mucous glands lining the large airways. or of organic substances such as hay dust. This common condition is characteristically produced by cigarette smoking. enzyme therapy to thin the mucus. After about 15 years of smoking. and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants. The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air.7 Diseases and Disorders of the Respiratory System
therefore untreated) aspiration into the airway of small foreign bodies. such as parts of plastic toys.
The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough.
the coexistence of these two conditions is known as chronic obstructive pulmonary disease. as measured by the velocity of a single forced expiration. All these changes together. can lead to disturbances in the distribution of ventilation and perfusion in the lung. treatment is mainly symptomatic. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. if severe enough. The mucus-producing cough will subside within weeks or months and may resolve altogether. It is not clear what determines the severity of these changes. By the time this occurs. consisting of expectorants and bronchodilators. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. whereas others may experience severe respiratory compromise after 15 years or less of exposure. Of primary importance is
. Some people can smoke for decades without evidence of significant airway changes. For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. drugs to suppress paroxysmal coughing may be necessary. but they must be used sparingly because they can be addictive and because expectoration is necessary. is severely compromised. Occasionally. Because the damage to the bronchial tree is largely irreversible. ventilatory ability has usually been declining rapidly for some years.7
The Respiratory System
inhalation of wood smoke from improperly ventilated cooking stoves. the ventilatory ability of the patient. though the rate of progression generally slows. though these produce the dominant symptom of chronic sputum production. Unfortunately. in a cigarette smoker. The changes are not confined to large airways. Smoking-related chronic bronchitis often occurs in association with emphysema.
7 Diseases and Disorders of the Respiratory System
the prevention of superimposed infections, either by careful watching for early signs or by using prophylactic antibiotics. Adjusting the patient’s living and working environments to the largely irreversible condition is an essential factor in treatment.
This irreversible disease consists of destruction of alveolar walls. It occurs in two forms, centrilobular emphysema, in which the destruction begins at the centre of the lobule, and panlobular (or panacinar) emphysema, in which alveolar destruction occurs in all alveoli within the lobule simultaneously. In advanced cases of either type, this distinction can be difficult to make. Centrilobular emphysema is the form most commonly seen in cigarette smokers, and some observers believe it is confined to smokers. It is more common in the upper lobes of the lung (for unknown reasons). By the time the disease has developed, some impairment of ventilatory ability has probably occurred. Panacinar emphysema may also occur in smokers, but it is the type of emphysema characteristically found in the lower lobes of patients with a deficiency in the antiproteolytic enzyme known as alpha-1 antitrypsin. Similar to centrilobular emphysema, panacinar emphysema causes ventilatory limitation and eventually blood gas changes. Other types of emphysema, of less importance than the two major varieties, may develop along the dividing walls of the lung (septal emphysema) or in association with scars from other lesions. A major step forward in understanding the development of emphysema followed the identification, in Sweden, of families with an inherited deficiency of alpha-1 antitrypsin, an enzyme essential for lung integrity. Members of affected families who smoked cigarettes
The Respiratory System
Emphysema destroys the walls of the alveoli of the lungs, resulting in a loss of surface area available for the exchange of oxygen and carbon dioxide during breathing. This produces symptoms of shortness of breath, coughing, and wheezing. In severe emphysema, difficulty in breathing leads to decreased oxygen intake, which causes headaches and symptoms of impaired mental ability. Encyclopædia Britannica, Inc.
commonly developed panacinar emphysema in the lower lobes, unassociated with chronic bronchitis but leading to ventilatory impairment and disability. Intense investigation of this major clue led to the “protease-antiprotease” theory of emphysema. It is postulated that cigarette smoking either increases the concentration of protease enzymes released in the lung (probably from white blood cells) or impairs the lung’s defenses against these enzymes or both. Although many details of the essential biochemical steps at the cellular level remain to be clarified, this represents a major step forward in understanding a disease whose
7 Diseases and Disorders of the Respiratory System
genesis was once ascribed to overinflation of the lung (like overdistending a bicycle tire). Chronic bronchitis and emphysema are distinct processes. Both may follow cigarette smoking, however, and they commonly occur together, so determination of the extent of each during life is not easy. In general, significant emphysema is more likely if ventilatory impairment is constant, gas transfer in the lung (usually measured with carbon monoxide) is reduced, and the lung volumes are abnormal. Development of high-resolution computerized tomography has greatly improved the accuracy of detection of emphysema. Some people with emphysema suffer severe incapacity before age 60. Thus, emphysema is not a disease of the elderly only. An accurate diagnosis can be made from pulmonary function tests, careful radiological examination, and a detailed history. The physical examination of the chest reveals evidence of airflow obstruction and overinflation of the lung, but the extent of lung destruction cannot be reliably gauged from these signs, and therefore laboratory tests are required. The prime symptom of emphysema, which is always accompanied by a loss of elasticity of the lung, is shortness of breath, initially on exercise only, and associated with loss of normal ventilatory ability and increased obstruction to expiratory airflow. The expiratory airflow from a maximum inspiration is measured by the “forced expiratory volume in one second,” or FEV1, and is a predictor of survival of emphysema. Chronic hypoxemia (lowered oxygen tension) often occurs in severe emphysema and leads to the development of increased blood pressure in the pulmonary circulation, which in turn leads to failure of the right ventricle of the heart. The symptoms and signs of right ventricular failure include swelling of the ankles (edema) and engorgement of the neck veins. These are portents of advanced lung disease in this condition. The
The Respiratory System
hypoxemia may also lead to an increase in total hemoglobin content and in the number of circulating red blood cells, as well as to psychological depression, irritability, loss of appetite, and loss of weight. Thus, the advanced syndrome of chronic obstructive lung disease may cause such shortness of breath that the afflicted person has difficulty walking, talking, and dressing, as well as numerous other symptoms. The slight fall in ventilation that normally accompanies sleep may exacerbate the failure of lung function in chronic obstructive lung disease, leading to a further fall in arterial oxygen tension and an increase in pulmonary arterial pressure. Unusual forms of emphysema also occur. In one form the disease appears to be unilateral, involving one lung only and causing few symptoms. Unilateral emphysema is believed to result from a severe bronchiolitis in childhood that prevented normal maturation of the lung on that side. “Congenital lobar emphysema” of infants is usually a misnomer, since there is no alveolar destruction. It is most commonly caused by overinflation of a lung lobe due to developmental malformation of cartilage in the wall of the major bronchus. Such lobes may have to be surgically removed to relieve the condition. Bullous emphysema can occur in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung tissue. This disease most commonly occurs between ages 15 and 30 and usually is not recognized until a bullous air space leaks into the pleural space, causing a pneumothorax.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by the
Frequent exacerbations. Sources of noxious particles that can cause COPD include tobacco smoke. which
. Therefore. COPD is distinguished pathologically by the destruction of lung tissue. Exacerbations are triggered by infection. It is a common disease. and by a tendency for excessive mucus production in the airway. are not always required.000 people in the United Kingdom and roughly 119. particularly lung cancer. Although primarily a lung disease. and each year about 30. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. antibiotics. either bacterial or viral. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin. which causes increased lung volume and manifests as breathlessness. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). tobacco-related condition. indicate a poor prognosis. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). particularly if severe enough to warrant hospital admission. which work against bacteria. which gives rise to symptoms of bronchitis. including muscle weakness and osteoporosis.7 Diseases and Disorders of the Respiratory System
combination of signs and symptoms of emphysema and bronchitis. air pollution. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger.000 people in the United States die from COPD. and the burning of certain fuels in poorly ventilated areas. which is replaced by holes characteristic of emphysema. it is increasingly recognized that COPD has secondary associations. Coughing up blood is not a feature of COPD and when present raises concern about a second.
e. high blood pressure. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD. Some COPD patients do not find oxygen attractive. bronchodilators). since they need to use it for 16 hours each day to derive benefit. especially for patients with frequent exacerbations. including noninvasive ventilation and surgical options (i.
Lung congestion is characterized by distention of blood vessels in the lungs and filling of the alveoli with blood as a result of an infection.e.e. oxygen is extremely flammable. which leads to further difficulties in mobility. lung transplantation and lung-volume reduction).to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy..7
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can be accomplished in most cases by cessation of smoking. Active congestion of the lungs is caused by
. and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. Specialized centres can offer treatments for patients with advanced disease. In addition. or cardiac insufficiencies (i. Inhaled corticosteroids are commonly prescribed.. inability of the heart to function adequately). A six. In COPD patients with low blood–oxygen levels. Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i.. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease. This should be followed by a community/home maintenance program or by repeat courses every two years.
Passive congestion is due either to high blood pressure in the capillaries. flooding them. rather than whole blood. The alveolar walls and the capillaries in them become distended with blood. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue. and the skin takes on a bluish tint as the disease progresses. and the precipitating causes may somewhat differ. The major complication arises in mild cases of pneumonia. and blood escapes through the capillary wall into the alveoli. Inflammatory edema results from influenza or bacterial pneumonia. The blood pressure becomes high in the alveolar capillaries. liquids. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. Left-sided heart failure—inability of the left side of the heart to pump sufficient blood into the general circulation—causes back pressure on the pulmonary vessels delivering oxygenated blood to the heart. there is a bloody discharge. The affected person shows difficulty in breathing.7 Diseases and Disorders of the Respiratory System
infective agents or irritating gases. although there is usually enough unaffected lung tissue for respiration. narrowing of the valve between the upper and lower chambers in the left side of the heart. and they begin to distend. when the remaining functioning tissue becomes infected. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. The walls of the alveoli also thicken and gas exchange is greatly impaired. or to relaxation of the blood capillaries followed by blood seepage. Mitral stenosis. caused by a cardiac disorder. and particles. causes chronic passive congestion. In
. Blood accumulates in the lower part of the lungs. Eventually the pressure becomes too great.
The Respiratory System
X-ray showing lung congestion caused by congestive heart failure. Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6241)
wet. A person with pulmonary edema experiences difficulty in breathing. compressive. There are three major types of atelectasis: adhesive. The term atelectasis can also be used to describe the collapse of a previously inflated lung. enlarged. because he or she is too weak to clear the fluids. with deep gurgling rattles in the throat.
Atelectasis is characterized primarily by the absence of air in the lungs. after reinflation of a collapsed lung. for unknown reasons. literally meaning “incomplete expansion” ¯ in reference to the lungs. After an operation. The person’s skin turns blue. the blood pressure rises and edema ensues. It can occur. are not expanded with air.7 Diseases and Disorders of the Respiratory System
mechanical edema the capillary permeability is broken down by the same type of heart disorders and irritants as in congestion. because of specific respiratory disorders. and. It may take only one or two hours for two to three quarts of liquid to accumulate. and obstructive. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed. These infants usually suffer from a disorder called respiratory distress syndrome. The lungs become pale. Adhesive atelectasis is seen in premature infants who are unable to spontaneously breathe and in some infants after only a few days of developing breathing difficulties. and heavy. if too great a volume of intravenous fluids is given. the person may actually drown in the lung secretions. This is typically caused by a failure to develop surface-active material
. their lungs show areas in which the alveoli. Excessive irradiation and severe allergic reactions may also produce this disorder. Acute cases can be fatal in 10 to 20 minutes. or air sacs. either partially or fully. The term is derived from the Greek words atele s and ektasis.
Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242)
.7 The Respiratory System
X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis. Dr.
which frequently enter with inhaled air. causing air trapped in the alveoli to be slowly absorbed by the blood. Local pressure can result from tumour growths. if these secretions become too abundant. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements. It may also occur as a complication of abdominal surgery. The symptoms in extreme atelectasis include low blood oxygen content. Mucous plugs can result that cause atelectasis. the anesthetic stimulates an increase in bronchial secretions. and consolidation of the lungs into a smaller mass. an enlarged heart. displacement of the heart toward the affected side. Generally. Other causes of obstruction include tumours or infection. When a person undergoes surgery. absence of respiratory movement on the side involved. The air passageways in the lungs normally secrete a mucous substance to trap dust. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. they can be pushed out of the bronchi by coughing or strong exhalation of air. After abdominal surgery. the respiratory tissue is replaced by fibrous scar tissue. and the muscles beneath the lungs may be weakened. Treatment for infants with this syndrome includes replacement therapy with surfactant. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out.7 Diseases and Disorders of the Respiratory System
(surfactant) in the lungs. Treatment for obstructive and compressive
. and respiratory function cannot be restored. and bacterial cells. soot. If a lung remains collapsed for a long period. or elevation of the diaphragm. which manifests as a bluish tint to the skin. Collapse is complete if the force is uniform or is partial when the force is localized.
infarcts that occur deep inside the lungs produce no pain. Pain is most severe on inhalation. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. Ordinarily. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. shoulders. infected. and neck. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. or it may be lower. or air bubbles in the bloodstream (both of these are instances of embolism).
Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. If the lung is congested. The pain may be localized around the rib cage. The section of dead tissue is called an infarct. or inadequately supplied with air.
. near the muscular diaphragm that separates the chest cavity from the abdomen. when the lungs are healthy. however. lung infarctions can follow blockage of a blood vessel. 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 obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. When pain is present it indicates pleural involvement. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. such blockages fail to cause death of tissue because the blood finds its way by alternative routes.7
The Respiratory System
atelectasis is directed toward removal of any obstruction or compressive forces.
Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). increased heartbeat. However. The disease has no manifestations in heterozygotes (i. when both
. diminished breath sounds. those individuals who have one normal copy and one defective copy of the particular gene involved). fever. also known as mucoviscidosis. moderate difficulty in breathing.
Cystic fibrosis. The dead tissue is replaced by scar tissue.000 live births) and is very rare in people of Asian ancestry. sticky mucus that clogs the respiratory tract and the gastrointestinal tract. and a dull sound heard when the chest is tapped. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. The disorder was long known to be recessive (i.e. coughing.7 Diseases and Disorders of the Respiratory System
The symptoms of infarcts are generally spitting up of blood. pleural rubbing.e. It is estimated to occur in 1 per 2.. It is much less common among people of African ancestry (about 1 per 17.. the chief symptom of which is the production of a thick. only persons inheriting a defective gene from both parents will manifest the disease). However.000 live births in these populations and is particularly concentrated in people of northwestern European descent. Cystic fibrosis was not recognized as a separate disease until 1938 and was then classified as a childhood disease because mortality among afflicted infants and children was high. Infarcts that do not heal within two or three days generally take two to three weeks to heal. is an inherited metabolic disorder. by the mid-1980s.
As a result. which is the most common cause of death of persons with cystic fibrosis. or CFTR. designated CFTR. foul-smelling stools are often the first signs of cystic fibrosis. Within the cells of the lungs and gut. lies in the middle of chromosome 7 and encodes a protein of the same name. In the digestive system. on the basis of chance. About 10
The Respiratory System
parents are heterozygous. recurrent pneumonia. sticky mucus accumulates in the lungs. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. In 1989 the defective gene responsible for cystic fibrosis was isolated.g. greasy. The gene. Bulky. they may expect that. one out of four of their offspring will have the disease. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet. The thick. the mucus-secreting and sweat glands) in the respiratory and digestive systems. chloride and sodium ions accumulate within cells. often with Staphylococcus aureus or Pseudomonas aeruginosa. the CFTR protein transports chloride across cell membranes and regulates other channels. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. called cystic fibrosis transmembrane conductance regulator. and the progressive loss of lung function are the major manifestations of lung disease. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. This results in chronic respiratory infections. plugging the bronchi and making breathing difficult. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. Chronic cough.. 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.
Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. a recombinant form of the enzyme deoxyribonuclease. facilitating its clearance from the lungs through coughing. The high salt content in perspiration is the basis for the “sweat test. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. lung transplantation may be considered. Mutations associated with cystic fibrosis can be detected in screening tests. which is powered by a compressor that sprays aerosolized drug into the airways. These tests are effective in the identification of adult carriers (heterozygotes). and fat. making it easier for patients to breathe.7 Diseases and Disorders of the Respiratory System
percent of infants with cystic fibrosis have intestinal obstruction at birth due to very thick secretions. Medications such as dornase alfa. In addition. Many patients with cystic fibrosis regularly take antibiotics. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. In severe cases.” which is the definitive diagnostic test for the presence of cystic fibrosis.
. In addition. in order to fight lung infections. who may pass a mutation on to their offspring. sometimes in aerosolized form. protein. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. as well as in the identification of newborns who may be at risk for the disorder. These agents may be administered by means of an inhaler or a nebulizer. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. are given to thin mucus.
which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. Gene therapy first emerged as a potential form of treatment in 1990. This first trial initially appeared to be successful. the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. the patients experienced severe side effects. These vectors were then transfected into the cultured cells. and the outcomes of clinical trials are marked by steady improvement. The latter. However. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene.7
The Respiratory System
Among the most promising treatments under investigation for cystic fibrosis is gene therapy. Since the 1990s. which subsequently incorporated the normal genes into their DNA. However. 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. 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. including lung inflammation and signs of viral infection. gene therapy for cystic fibrosis has undergone significant refinement. and adenovirus associated virus. As a result. cationic liposomes. Delivery systems under investigation include cationic polymer vectors.
. has proved particularly effective in laboratory studies using human lung tissue. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. since increased expression of the CFTR protein was observed shortly after treatment.
Aside from administration of supplemental oxygen. Other common changes are enlargement of the lymph
.7 Diseases and Disorders of the Respiratory System
Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. pulmonary function testing shows a reduction in lung volume. in different organs. or granulomas. In addition. The average duration of survival from diagnosis is four to six years. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. there is no effective treatment. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. called rales or “Velcro crackles. the lung is commonly involved. The disease most commonly manifests between ages 50 and 70. with insidious onset of shortness of breath on exertion.” are heard through a stethoscope applied to the back in the area of the lungs.
Sarcoidosis and Eosinophilic Granuloma
Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. A dry cough is common as well. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. Some individuals have clubbed fingertips and toes. Some individuals may benefit from single or double lung transplantation. Sharp crackling sounds. some people live 10 years or longer. however.
The disease usually remits without treatment within a year or so. Eosinophilic granuloma.” leaving the lung with some permanent cystic changes. skin changes. a complex mixture of protein and lipid (fat) molecules. Although its cause is unknown. nerve sheaths are inflamed. the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. also known as histiocytosis X. When too much surfactant is released from the alveolar cells. The alveoli are air sacs. inflammation in the eye.
Pulmonary Alveolar Proteinosis
Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. The kidney is not commonly involved. It causes lesions in lung tissue and sometimes also in bone tissue. minute structures in the lungs in which the exchange of respiratory gases occurs. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. Eosinophilic granuloma is a lung condition that may spontaneously “burn out. In most cases the disease is first detected on chest radiographs. or when the lung fails to remove the
. is a disease associated with the excess production of histiocytes. a subgroup of immune cells. Occasionally. leading finally to lung fibrosis and respiratory failure. leading to signs of involvement in the affected area. the incidence is greatly increased in cigarette smokers. but some changes in blood calcium levels occur in a small percentage of cases.7
The Respiratory System
glands at the root of the lung. and liver dysfunction. but often there is little interference with lung function. The gas molecules must pass through a cellular wall. but in a small proportion of cases it progresses. Evidence of granulomas in the lung may be visible.
Immunologic Conditions of the Lung
The lung is often affected by generalized diseases of the blood vessels. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. it is sometimes fatal. and spontaneous improvement has been known to occur. The fluids drawn back out of the lungs have been found to have a high content of fat. Persons affected are usually between ages 20 and 50. X-rays most frequently show evidence of excess fluids in the lungs. The skin becomes tinged with blue in the most serious cases. Treatment involves removal of the material by a rinsing out of the lungs (lavage). if treated. but subsequent treatments are often necessary. The disease can exist without causing symptoms for considerable periods. One lung at a time is rinsed with a saltwater solution introduced through the windpipe. There may also be general fatigue and weight loss.7 Diseases and Disorders of the Respiratory System
surfactant. an acute inflammatory disease of the blood vessels believed to be of immunologic origin. but its cause is not fully understood. Pulmonary hemorrhage also occurs as part of a condition
. is an important cause of pulmonary blood vessel inflammation. The condition has been successfully treated by exchange blood transfusion. Sometimes the lesions totally clear up after one procedure. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. but rarely so. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. and it is often accompanied by chest pain and a dry cough. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. The precipitating cause of the disease is unknown. Wegener granulomatosis.
lung cancer is the second leading cause of death from cancer globally. lung cancer emerged as the leading cause of cancer deaths worldwide. More rarely. it has surpassed breast cancer. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. In the United States.
Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs. 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 21st century.3 million deaths each year. following breast cancer. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. a slowly obliterative disease of small airways (bronchiolitis) occurs. however. which is also believed to have an immunologic basis. Pleural effusions may occur. accurate diagnosis has been much improved by refinements in radiological methods. 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. These conditions have only recently been recognized and differentiated.7
The Respiratory System
known as pulmonary hemosiderosis. 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 lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus.
. Lung cancer was first described by doctors in the mid-19th century. by the use of pulmonary function tests. In the early 20th century it was considered relatively rare. leading finally to respiratory failure. In women. and the lung parenchyma may be involved.
secondhand smoke accounts for an estimated 3. small-cell
. tar refiners. The risk is also greater for those who started smoking at a young age. The most common symptoms include shortness of breath. as do some workers in hydrocarbon-related processing. Lung cancer is rarely caused directly by inherited mutations. In cases where the cancer has spread beyond the lungs. visible lumps. According to the American Cancer Society. and roofers. between 80 and 90 percent of all cases are caused by smoking.400 deaths from lung cancer in nonsmoking adults in the United States each year. welders. Of the two basic forms. Uranium and pitchblende miners. unexplained weight loss. Other risk factors include exposure to radon gas and asbestos. and susceptibility to lower respiratory infections. chest pain. such as coal processors. In countries with a prolonged history of cigarette smoking. Heavy smokers have a greater likelihood of developing the disease than do light smokers. jaundice. or bone pain may occur.7 Diseases and Disorders of the Respiratory System
Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. Types of Lung Cancer Once diagnosed. chromium and nickel refiners. and workers exposed to halogenated ethers also have an increased incidence. Tumours can begin anywhere in the lung. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. a persistent cough or wheeze. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. the tumour’s type and degree of invasiveness are determined. bloody sputum.
Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. Treatment. pleura.or column-shaped. but it is the most common type of lung cancer in the United States. the survival rate is very low.7
The Respiratory System
carcinoma accounts for 20 to 25 percent of all cases and non-small-cell carcinoma is responsible for the remainder. and Prevention Lung cancers are often discovered during examinations for other conditions. and it often develops in the larger bronchi of the central portion of the lungs. oval. adenocarcinoma. SCLC is the most aggressive type of lung cancer. About 10 percent of all lung cancers are large-cell carcinomas. and large-cell carcinoma. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. also called epidermoid carcinomas.
. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. and they form structures that resemble glands and are sometimes hollow. and both lungs or metastasis to other organs. There is some dispute as to whether these constitute a distinct type of cancer or are merely a group of unusual squamous cell carcinomas and adenocarcinomas. or shaped like oat grains. Diagnosis. also called oat-cell carcinoma. Because it tends to spread quickly before symptoms become apparent. Cancer cells may be detected in sputum. Tumours often originate in the smaller. scalelike cells. Cells of adenocarcinoma are cube. peripheral bronchi. Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. Small-cell carcinoma (SCLC). Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. It is characterized by cells that are small and round. is rarely found in people who have never smoked. This tumour is characterized by flat.
positron emission tomography (PET) scans. the five-year survival rate is about 50 percent. For example. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. Noninvasive methods include X-rays. and magnetic resonance imaging (MRI). and the type of cancer. Lung surgery is serious and can lead to complications such as pneumonia or bleeding. chemotherapy. Even when it is detected early. computed tomography (CT) scans. or the entire lung (pneumonectomy). Surgery involves the removal of a cancerous segment (segmentectomy). treatments for lung cancer include surgery. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery.7 Diseases and Disorders of the Respiratory System
a needle biopsy may be used to remove a sample of lung tissue for analysis. Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. The choice of treatment depends on the patient’s general health. and radiation. a lobe of the lung (lobectomy). The type of treatment an individual patient receives may also be based on the results of genetic screening. For this reason. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. which can identify mutations that render some lung cancers susceptible to specific drugs. the stage or extent of the disease. As with most cancers. 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. Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or
. lung cancer has a poorer prognosis than many other cancers.
Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the
. causing side effects that are similar to radiation therapy. noninvasive cysts of different kinds are also found in the mediastinum. Side effects include vomiting. asbestos. which relies on heat derived from microwave energy to kill cancer cells. Enlargement of lymph glands in this region is common. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. Testing for radon gas and avoiding exposure to coal products. together with the many important structures situated within it. diarrhea. The probability of developing lung cancer can be greatly reduced by avoiding smoking. but these chemicals also attack normal cells to varying degrees. or additional damage to the lungs.7
The Respiratory System
following surgery to destroy small amounts of cancerous tissue. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. and other airborne carcinogens also lowers risk. Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. Chemotherapy uses chemicals to destroy cancerous cells. fatigue.
diseases of the MediastinuM and diaphragM
The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. Smokers who quit also reduce their risk significantly.
This area contains the heart. the released air seeks an area of escape. the extra gas pressure is relieved by exhaling. the expanding air may compress the respiratory passageways. and the lungs begin to expand because the air inside has less pressure to contain it. there is no difficulty. When the alveoli of the lungs rupture because of traumatic injury or lung disease. Air trapped in the mediastinum expands as the diver continues to rise. If the diver holds his or her breath. or they can travel through the lung tissue to other areas of the body. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. and collapse blood vessels vital to circulation.
. causing an air embolism. or scar tissue. the external pressure upon his or her body increases. rises too rapidly. One pathway that the air can follow is through the lung tissue into the mediastinum. where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. or has respiratory obstructions such as cysts.7 Diseases and Disorders of the Respiratory System
heart and central blood vessels. While the diver remains deeply submerged. If the diver breathes normally or exhales as he or she ascends at a moderate rate. which do not permit sufficient release of air. This usually occurs as a result of lung rupture. however. As a diver descends. the external pressure decreases. and the trachea. making breathing difficult. The pressure may cause intense pain beneath the rib cage and in the shoulders. mucus plugs. Air bubbles can then enter the veins and capillaries of the circulatory system directly. major blood vessels. the lungs become overinflated and rupture. when he or she begins to ascend again. main bronchi. The air the diver breathes is more dense and concentrated than the air breathed on the surface.
as occurs in emphysema. respiratory failure. In some persons the diaphragm may be incompletely formed at birth. If there is respiratory or circulatory distress. this can lead to herniation of the abdominal viscera through the diaphragm.
. The function of the diaphragm may be compromised when the lung is highly overinflated. diaphragmatic fatigue may limit the exercise capability of affected persons. For example.7
The Respiratory System
The symptoms of mediastinal emphysema may range from pain under the breastbone. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. and cyanosis (blue colouring of the skin). In many cases the cause of the paralysis cannot be determined. the air will be absorbed by the body. especially when the subject is recumbent (lying down). bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. and shallow breathing to unconsciousness. although some shortness of breath on exertion is often present. shock. the victim must be recompressed in a hyperbaric chamber so that the body can resume its essential functions before the air is removed. In cases in which the symptoms are not severe. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air.
affected persons are highly sensitive to substances such as dust or pollen. First. many of which are acute in nature. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. severe respiratory disease may ensue. such as asbestos and coal dust.
allergic lung diseases
There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. altitude sickness. In the case of allergies. leading to cancer and substantial loss of lung function. the lungs are exposed to the outside environment. hence. and.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. causes respiratory disease in otherwise healthy workers. reducing exposure to the irritant relieves the symptoms of their condition. and drowning are other examples of acute conditions that can result in respiratory failure. In occupational disease.
. Respiratory function can be severely compromised by a variety of other conditions. For most affected persons. Carbon monoxide poisoning. exposure to harmful irritants. In some cases of occupational exposure. such as respiratory distress syndrome. decompression sickness. traumatic conditions. however.
chest tightness. Asthmatic episodes may begin suddenly or may take days to develop. Among adults. the lung contains a very large vascular bed. women are affected more often than men. such as chemicals. and. dust mites. or animal dander.7
The Respiratory System
particles of foreign substances such as pollen may be deposited directly in the lungs. In addition. Adult asthma is sometimes linked to exposure to certain materials in the workplace. asthma may develop in response to allergens. Adults who develop asthma may also have chronic rhinitis. approximately half of all cases occur in persons younger than age 10. wood dusts. stress may exacerbate symptoms. such as pollen. it is often associated with an inherited susceptibility to allergens— substances. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. In adults. and exercise may cause it as well. that may induce an allergic reaction.
Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. which may be involved in any general inflammatory response. and breathlessness that range in severity from mild to life-threatening. the walls of the bronchial tree contain smooth muscle that is very likely to be stimulated to contract if histamine is released by cells affected by the allergic reaction. nasal polyps. however. or sinusitis. causing episodes of wheezing. second. weather conditions. boys being affected more often than girls. but viral infections. coughing. When asthma develops in childhood. These substances provoke both allergic and nonallergic forms of the disease. aspirin. Although an initial episode can occur at any age. third. In
. and grains. The most common and most important of these is asthma.
and severe persistent. swelling and inflammation of the inner airway space (lumen) cause fluid buildup and infiltration by immune cells and excessive secretion of mucus into the airways. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. Inc. terminal bronchial tubes. which can be divided into four categories: mild intermittent. Although the mechanisms underlying an asthmatic episode are not fully understood.
most of these cases. Asthma is classified based on the degree of symptom severity. smooth muscles that surround the airways spasm.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
During normal breathing. moderate persistent. in general
. Encyclopædia Britannica. symptoms will subside if the causative agent is removed from the workplace. air is obstructed from circulating freely in the lungs and cannot be expired. Consequently. During an asthma attack. mild persistent. narrower passages (bronchioles) and finally into the tiny. which results in tightening of the airways.
swelling and inflammation of the bronchial tubes. The inflamed. Asthma medications are categorized into three main types: anti-inflammatory agents. such as shortacting beta2-agonists and ipratropium bromide. air is inspired but cannot be expired). which are anti-inflammatory medications often prescribed for children. which are the most potent and effective anti-inflammatory medications available. or systemic corticosteroids. which are involved in mediating airway constriction and inflammation. Quick-relief medications may include bronchodilators. which are bronchodilators. and zileuton and zafirlukast. and excessive secretion of mucus into the airways. which suppress inflammation. are in clinical trials. or they may be used to provide rapid relief from constriction of airways (quick-relief medications). long-acting beta2-agonists and methylxanthines (e. and leukotriene modifiers.. mucus-clogged airways act as a one-way valve (i. The obstruction of airflow may resolve spontaneously or with treatment. Agents that block enzymes called phosphodiesterases. theophylline). These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). These
. These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi.g. which relax smooth muscle constriction and open the airways.7
The Respiratory System
it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system. cromolyn sodium and nedocromil. Long-term control medications include corticosteroids. A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes.. bronchodilators.e. which are leukotriene modifiers. which interrupt the chemical signaling within the body that leads to constriction and inflammation.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
drugs are designed to be long-lasting—administered once per day via inhalation—and are expected to be safer than traditional medications. which may cause cardiovascular damage. A person with this condition must be hospitalized to receive oxygen and other treatment. in many underdeveloped tropical regions of the world. the number of asthma cases has increased steadily. can relieve symptoms of allergy and asthma. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. The ability to recognize the early warning signs of an impending episode is important. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. A prolonged asthma attack that does not respond to medication is called status asthmaticus. exposure to secondhand smoke. a species of hookworm. particularly among children. In developed countries and especially in urban areas. smoking. Further investigation of this “helminthic therapy” in larger sample populations is under way. crowded living conditions. and even cockroaches have been blamed for the increase. Reasons for this dramatic surge in asthma cases. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. are not entirely clear.
. millions of people are infected with Necator americanus. Air pollution. In those areas. Today asthma affects more than 7 percent of children and about 9 percent of adults. However. too few to cause hookworm disease. very few people are affected by allergies or asthma. In addition to managing asthma with medications. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma.
like other allergic diseases. The most effective long-term treatment is immunotherapy. chiefly those depending upon the wind for cross-fertilization. is a common seasonal condition caused by allergy to grasses and pollens. 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). nasal congestion. pertussis vaccine.
Hay fever. may give rise to asthma. Seasonally recurrent bouts of sneezing. In a reverse scenario. Symptoms may be aggravated by emotional factors.7
The Respiratory System
There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. and tearing and itching of the eyes caused by allergy to the pollen of certain plants. also known as allergic rhinitis. such as dermatitis or asthma. shows a familial tendency and may be associated with other allergic disorders.
. Antibiotics may also interfere with immune development. 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. such as ragweed in North America and timothy grass in Great Britain. Although not yet successfully confirmed. 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. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. which irritates the small blood vessels and mucus-secreting glands. studies have indicated that only one vaccine.
Louise K. Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America. Broman—Root Resources
.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
Giant ragweed (Ambrosia trifida) is a common cause of hay fever.
in the west of England. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). with shortness of breath persisting after the radiographic changes have disappeared. granulomas.7
The Respiratory System
Hypersensitivity pneumonitis is an important group of conditions in which the lung is sensitized by contact with a variety of agents and in which the response to reexposure consists of an acute pneumonitis. If untreated. or becoming opaque) in the basal regions of the lung on the chest radiograph. One of these illnesses is the so-called farmer’s lung. may be found in the lung. and in France. Variously known as pigeon breeder’s lung or bird fancier’s lung. Farmer’s lung is common in Wisconsin. In more chronic forms of the condition. with inflammation of the smaller bronchioles. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. and there may be measurable interference with diffusion of gases across the alveolar wall. This causes an acute febrile illness with a characteristically fine opacification (clouding. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). the condition may become chronic. A similar group of diseases occurs in those with close contact with birds. these represent different kinds of allergic responses to proteins from birds. and canaries. on the eastern seaboard of Canada. or aggregations of giant cells. alveolar wall edema. particularly proteins contained in the excreta of pigeons. Airflow obstruction in small airways is present. after
. budgerigars (parakeets).
Runk/Schoenberger from Grant Heilman
exposure to redwood sawdust.
occupational lung disease
Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical
. The disease may present as an atypical nonbacterial pneumonia and may be labeled a viral pneumonia if careful inquiry about possible contacts with known agents is not made. or in response to a variety of other agents. It is occasionally attributable to Aspergillus.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
Some species of the fungi genus Aspergillus can cause allergic reactions and mild pneumonia in susceptible individuals. but sometimes the precise agent cannot be identified. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented.
of the lung. chromate. although silica exposure is also involved in many cases. iron. Among inorganic dusts. or air sacs. usually over a prolonged period of time. and emphysema in the most severe cases. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. while milder irritants produce symptoms of lung disease only with massive exposure. is the most common cause of severe pneumoconiosis. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung.2 ounce) in the lung can produce disease. barium. silica. notably silica and asbestos. and coal dusts are other inorganic substances known to produce pneumoconiosis. tin. Inhaled dust collects in the alveoli. The total dust load in the lung. If enough scar tissue forms. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. The type and severity of disease depends on the composition of the dust. Graphite. beryllium. chronic bronchitis. shortness of breath. As little as 5 or 6 grams (about 0. encountered in numerous occupations. clay. the early symptoms of mild pneumoconioses include chest tightness. the toxic effects of certain types of dust. small quantities of some substances. lung function is seriously impaired. often after relatively brief
The Respiratory System
irritants. Asbestos. produce grave reactions. and the clinical symptoms of pneumoconiosis are manifested. progressing to more serious breathing impairment. and cough. and infections of the already damaged lung can accelerate the disease process. and aluminum dusts can cause a more severe pneumoconiosis.
Prolonged exposure to organic dusts such as spores of molds from hay. ammonia. quarry workers. The chemicals themselves may scar the delicate lung tissues. when inhaled. and workers whose jobs involve grinding. nitrogen dioxide. even in previously nonallergic persons. and barley can produce lung disease through a severe allergic response within a few hours of exposure. having been recognized in knife grinders and potters in the 18th century. and buffing. Histamines cause the air passages to constrict. polishing. The
. In most instances. impeding exhalation. Asbestosis has also been associated with cancers of the lung and other organs. sugarcane. acid. stonecutters. flax. the patient may recover completely or may suffer from chronic bronchitis or asthma. and chloride. or hemp that. and their irritant effect may cause large amounts of fluid to accumulate in the lungs.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
exposure to massive amounts of dust. stimulate histamine release. tunnelers. Chemical irritants that have been implicated in lung disease include sulfur dioxide. Brown lung disease in textile workers is also a form of pneumoconiosis. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. malt. Silicosis is one of the oldest industrial diseases.) The disease occurs most commonly in miners. Once exposure to the chemical ceases.
Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. sandblasting. (Silica is the chief mineral constituent of sand and of many kinds of rock. mushrooms. which are quickly absorbed by the lining of the lungs. and it remains one of the most common dust-induced respiratory diseases in the developed world. caused by fibres of cotton.
and particles of one to three microns do the most damage.7
The Respiratory System
disease rarely occurs with exposures to concentrations of less than 6.000 per litre) of air.000. difficulty in breathing. cannot be digested by the macrophages and instead kill them. There is no cure for silicosis. The symptoms of silicosis are shortness of breath that is followed by coughing. however. is a respiratory disorder caused by repeated inhalation of
. These whorls of fibrous tissue may spread to involve the area around the heart. that serve to protect the body from bacterial invasion. also known as coal-worker’s pneumoconiosis. Silica particles. Lung volume is reduced. the openings to the lungs. control of the disease lies mainly in prevention. In the past a large proportion of sufferers of silicosis died of tuberculosis. and. and weakness. and pneumonia. Only very small silica particles less than 10 microns (0.
Black lung. since there is no effective treatment. The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses. Silicosis predisposes a person to tuberculosis. and gas exchange is poor. These symptoms are all related to a fibrosis that reduces the elasticity of the lung.000 particles of silica per cubic foot (about 210. emphysema. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. In the actual disease process. though this has changed with the availability of drug therapies for that disease.0004 inch) in diameter penetrate to the finer air passages of the lungs. and the abdominal lymph nodes. called macrophages. 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.
It may be the best known occupational illness in the United States. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to
. It is not clear. tuberculosis is also more common in victims of black lung. The first disease recognized to be caused by asbestos was asbestosis. Georgius Agricola. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. and it is now widely recognized.
Asbestosis and Mesothelioma
The widespread use of asbestos as an insulating material during World War II. ceiling tiles. There is strong evidence that tobacco smoking aggravates the condition. a German mineralogist. as coal dust often is contaminated with silica. first described lung disease in coal miners in the 16th century. and the extent of disease is clearly related to the total dust exposure. which causes similar symptoms. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. The disease is most commonly found among miners of hard coal. whether coal itself is solely responsible for the disease. brake linings.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
coal dust over a period of years. The early stages of the disease (when it is called anthracosis) usually have no symptoms. however. but it also occurs in soft-coal miners and graphite workers. and as a fire protectant sprayed inside buildings. Onset of the disease is gradual. led to a virtual epidemic of asbestos-related disease 20 years later. which produces characteristic changes in the lungs that can be identified in chest X-rays and that can impair lung function at an early stage. and later in flooring. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling.
there was a major increase in the risk for lung cancer. especially when associated with cigarette smoking. It is not yet understood exactly why asbestos devastates the tissues of the lungs. Not all types of asbestos are equally dangerous. The risk of mesothelioma in particular appears to be much higher if crocidolite. These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. inhalation of asbestos remains a significant risk for the workers removing the material. thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. is inhaled than if chrysotile is inhaled.7
The Respiratory System
thickening of the pleura. In most cases. although in occasional cases pleuritis is very aggressive and thus may produce symptoms. Malignant mesothelioma is rare and unrelated to cigarette smoking. But exposure to any type of asbestos is believed to increase the risk of lung cancer. a blue asbestos that comes from South Africa. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. when both cigarette smoking and asbestos exposure occurred. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. and. As far as is known. but survival after diagnosis is less than two years. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. All
. Asbestos has been suspected to play a role in stimulating certain cellular events. all the respiratory changes associated with asbestos exposure are irreversible. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.
Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing
The Respiratory System
beryllium alloys, and a slow-developing chronic disease occurring in scientific and industrial workers who are exposed to beryllium-containing fumes and dust. The acute disease involves both skin and lungs, causing a burning rash, eye irritation, nasal discharge, a cough, and chest tightness. The skin disease is caused by direct contact with beryllium salts and the lung disease by inhalation of metal dust or beryllium compounds. Most of those affected by acute berylliosis recover within a few months, but a small number of patients develop a highly fatal inflammation of the lung within 72 hours after a brief, massive exposure to beryllium. The chronic disease may occur more than 15 years after exposure, although the later it develops, the milder it is likely to be. It generally causes shortness of breath, especially after exercise, exhaustion, and a dry cough and can produce a permanent, though moderate, disability.
Byssinosis, or brown lung, is a respiratory disorder caused by inhalation of an endotoxin produced by bacteria in the fibres of cotton, flax, hemp, and other textiles. Byssinosis is common among textile workers, who often inhale significant amounts of cotton dust. Cotton dust may stimulate inflammation that damages the normal structure of the lung and causes the release of histamine, which constricts the air passages. As a result, breathing becomes difficult. Over time the dust accumulates in the lung, producing a typical discoloration that gives the disease its common name. Byssinosis was first recognized in the 17th century and was widely known in Europe and England by the early 19th century. Today it is seen in most cotton-producing
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
regions of the world. Several years of exposure to cotton dust are needed before byssinosis develops, and workers with lower grade disease usually recover completely upon leaving the industry or moving into an area with less dust. Persons with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure continues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Because cotton is by far the most common cause of byssinosis, this form of the condition has been variably known as cotton-dust asthma and cotton-mill fever.
Respiratory Toxicity of Industrial Chemicals
Toluene diisocyanate, used in the manufacture of polyurethane foam, may cause occupational asthma in susceptible individuals at very low concentrations. In higher concentrations, such as may occur with accidental spillage, it causes a transient flulike illness associated with airflow obstruction. Prompt recognition of this syndrome has led to modifications in the industrial process involved. Although the acute effects of exposure to many of these gases and vapours are well documented, there is less certainty about the long-term effects of repeated low-level exposures over a long period of time. This is particularly the case when the question of whether work in a generally dusty environment has contributed to the development of chronic bronchitis or later emphysema. In other words, whether such nonspecific exposures increase the risk of these diseases in cigarette smokers. Many chemicals can damage the lung in high concentration: these include oxides of nitrogen, ammonia,
The Respiratory System
chlorine, oxides of sulfur, ozone, gasoline vapour, and benzene. In industrial accidents, such as occurred in 1985 in Bhopal, India, and in 1976 in Seveso, near Milan, people in the neighbourhood of chemical plants were acutely exposed to lethal concentrations of these or other chemicals. The custom of transporting dangerous chemicals by rail or road has led to the occasional exposure of bystanders to toxic concentrations of gases and fumes. Although in many cases recovery may be complete, it seems clear that long-term damage may occur.
Disability and Attribution of Occupational Lung Diseases
Occupational lung diseases are of social and legal importance. In such cases, respiratory specialists must assess the extent of an individual’s disability and then form an opinion on whether an individual’s disability can be attributed to an occupational hazard. Pulmonary function testing and tests of exercise capability provide a good indication of the impact of a disease on the physical ability of a patient. However, it is much more difficult to decide how much of a patient’s disability is attributable to occupational exposure. If the exposure is historically known to cause a specific lesion in a significant percentage of exposed persons, such as mesothelioma in workers exposed to asbestos, attribution may be fairly straightforward. In many cases, however, the exposure may cause only generalized pulmonary changes or lung lesions for which the precise cause cannot be determined. These instances may be complicated by a history of cigarette smoking. Physicians asked to present opinions on attributability before a legal body frequently must rely on the application of probability statistics to the individual case, a not wholly satisfactory procedure.
slight fever. Over time. environmental pollutants. to an increased respiratory rate. and metabolic disorders. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism. When severe. conditions arising from exposure to extremes in atmospheric pressure. The causative factors of these conditions may include accidents. Early mobilization after surgery or childbirth is considered an important preventive measure. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. in which the pressure in the main pulmonary artery is persistently increased. which has usually formed in the veins of the legs or of the pelvis. The consequences of embolism range from sudden death. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. This occurs most often during a postoperative period when the affected individual is immobilized in bed. these changes are known as a pulmonary infarction. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. a clot is replaced with
. which occurs during mountain climbing and diving.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
other respiratory conditions
Other respiratory conditions.
The lung is commonly involved in disorders of the circulation. and occasionally some pleuritic pain over the site of the infarction. when the infarction is massive. In addition. comprise a diverse group of diseases and disorders. ranging from poor pulmonary circulation to carbon monoxide poisoning. toxic gases.
In addition to chest X-rays and basic pulmonary function tests. follows left ventricular failure. long-term evaluation and treatment. ultimately. lung transplantation is necessary.7
The Respiratory System
an adherent fibrous material in the pulmonary arteries. and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. usually as a consequence of coronary arterial disease. usually after increasing disability with severe shortness of breath. a diagnosis of pulmonary hypertension is often confirmed following an electrocardiogram (EKG) to assess electrical function of the heart. In some cases. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. Prostacyclin can sometimes be given in oral or inhaled forms. a condition of unknown origin. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. When the
. causing shortness of breath on exertion and. affected individuals require careful. right ventricular heart failure. The obstructing lesions can be surgically removed in some instances. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. In primary pulmonary hypertension. with consequent shortness of breath. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. While some medications such as calcium channel blockers may be taken orally. thereby relieving symptoms of breathlessness.
Autopsies of children who had succumbed to the disorder revealed that the air sacs (alveoli) in their lungs had collapsed and a “glassy” (hyaline) membrane had developed in the alveolar ducts. These changes contribute to the shortness of breath and account for the blood staining of the sputum.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
valve between the left atrium of the heart and the left ventricle is thickened and deformed by rheumatic fever (mitral stenosis). The disorder arises because of a lack of surfactant. This complication is especially common in premature newborns.5 kg. In infants it is also called hyaline membrane disease.5 pounds). cyanosis (a bluish tinge to the skin or mucous membranes). low-birth-weight infants (those weighing less than 2. It is characterized by extremely laboured breathing. The syndrome was formerly the leading cause of death in premature infants. Although respiratory distress syndrome occurs mostly in premature. which does the work of the lungs by oxygenating the
. or approximately 5. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. particularly those born to diabetic mothers. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. Before the advent of effective treatment. respiratory distress syndrome of infants was frequently fatal. and abnormally low levels of oxygen in the arterial blood. 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. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator.
Respiratory Distress Syndrome
Respiratory distress syndrome is a condition that can affect infants or adults.
Prize cattle at an agricultural show also died in the same period as a result of the air pollution. although superimposed infection or multiple organ failure can result in death. but not all. This episode spurred renewed attention to this problem. of the victims already had chronic heart or lung disease. exposure of the lung to gases. Acute respiratory distress syndrome carries about a 50 percent mortality rate. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. bacterial or viral pneumonia. In adults. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. 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. Most children who survive have no aftereffects.
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 4.7
The Respiratory System
blood and removing carbon dioxide. Many causes of respiratory distress syndrome of adults have been identified. Life-support treatment with assisted ventilation rescues many patients. This syndrome is known as acute respiratory distress syndrome of adults. widespread bilateral lung injury. aspiration of material into the lung (including water in near-drowning episodes). Recovery and repair of the lung may take months after clinical recovery from the acute event. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. which had been intermittently considered since the 14th century
.000 people during that week and the subsequent three weeks. Many.
This begins with the emission
Air pollution begins as emissions from sources such as industrial smokestacks. common in many cities using coal as heating fuel. and finally the passage of legislation banning open coal burning. Photos. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
in England. the factor most responsible for the pollution. together with the bright sunlight and frequently stagnant air. leads to the formation of photochemical smog.com/Jupiterimages 181
. and possibly lung cancer. is associated with excess mortality and increased prevalences of chronic bronchitis. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles. respiratory tract infections in the young and old. The large number of automobiles in that city. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories. This form of pollution.
chest irritation with cough. including Mexico City. The indoor environment can be important in the genesis of respiratory disease. In developing countries. and finally. Eye irritation.7
The Respiratory System
of nitrogen oxide during the morning commuting hour. In developed countries. through a complex series of reactions in the presence of hydrocarbons and sunlight. and possibly the exacerbation of asthma occur as a result. Bangkok. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely.12 part per million. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. followed by the formation of nitrogen dioxide by oxygenation. Ozone is the most irritant gas known. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children. and the impact of these exposures is an area of intense scientific investigation. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. Such exposures are common in the lives of millions of people.
. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. A tightly sealed house may act as a reservoir for radon seeping in from natural sources. and repeated exposures may lead to lung cancer. and São Paulo. which begins as emissions of nitrogen oxides. These levels are commonly exceeded in many places.
The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. leaving only 60 percent available to bind to oxygen). For this reason. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). The carbon monoxide inhaled by smokers who smoke more than two packs of cigarettes a day may cause up to 10 percent hemoglobin saturation with carbon monoxide. including combustion of gas in automobile engines.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
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. Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. 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. the subject feels dizzy and is unable to perform simple tasks.
. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. Judgment is also impaired. 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. as part of his detailed analysis of atmospheres in underground mines. a condition in which hemoglobin is deficient.
including the blood. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. asthma. shock.7
The Respiratory System
Acidosis is an abnormally high level of acidity. including the blood. or high level of alkalinity. 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. There are two primary types of acidosis: respiratory and metabolic. and renal failure. Respiratory alkalosis results from hyperventilation. or low level of alkalinity. such as pneumonia or emphysema. among others.
Alkalosis and Hyperventilation
Alkalosis is an abnormally low level of acidity. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). or pneumonia. This may be caused by severe acute or chronic lung disease. certain drugs or poisons. Metabolic alkalosis results from either acid loss. which may be caused by anxiety. Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. in the body fluids. or by certain medications that suppress respiration in excessive doses. pulmonary embolism. Causes of metabolic acidosis include uncontrolled diabetes mellitus. congestive heart failure. in the body fluids. or bicarbonate gain. During hyperventilation the rate of
. Hyperventilation is defined as a sustained abnormal increase in breathing. Alkalosis may be either metabolic or respiratory in origin. such as general anesthetic agents.
accumulation of fluid in the alveolar spaces can interfere with gas exchange. Inc.
. In addition. Encyclopædia Britannica. such as respiratory acidosis or hyperventilation.7
Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. causing symptoms such as shortness of breath. Imbalances in the exchange of these gases can lead to dangerous respiratory disorders.
The Respiratory System
removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, respiratory alkalosis ensues. In turn, alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, including light-headedness and tingling of the fingertips. Severe hyperventilation can cause transient loss of consciousness. Anxiety is the most common cause of hyperventilation. Panic disorder, a severe episodic form of anxiety, usually causes hyperventilation with resultant symptoms. Treatment of recurrent hyperventilation begins with a complete explanation by the patient of the condition and the symptoms it causes. Some people benefit from psychotherapy and medications to deal with the underlying anxiety.
Hypoxia is a condition of the body in which the tissues are starved of oxygen. In its extreme form, where oxygen is entirely absent, the condition is called anoxia. There are four types of hypoxia: (1) the hypoxemic type, in which the oxygen pressure in the blood going to the tissues is too low to saturate the hemoglobin; (2) the anemic type, in which the amount of functional hemoglobin is too small, and hence the capacity of the blood to carry oxygen is too low; (3) the stagnant type, in which the blood is or may be normal but the flow of blood to the tissues is reduced or unevenly distributed; and (4) the histotoxic type, in which the tissue cells are poisoned and are therefore unable to make proper use of oxygen. Diseases of the blood, the heart and circulation, and the lungs may all produce some form of hypoxia.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The hypoxemic type of hypoxia is due to one of two mechanisms: 1. a decrease in the amount of breathable oxygen—often encountered in pilots, mountain climbers, and people living at high altitudes— due to the reduced barometric pressure, or 2. cardiopulmonary failure in which the lungs are unable to efficiently transfer oxygen from the alveoli to the blood. In the case of anemic hypoxia, either the total amount of hemoglobin is too small to supply the body’s oxygen needs, as in anemia or after severe bleeding, or hemoglobin that is present is rendered nonfunctional. Examples of the latter case are carbon monoxide poisoning and methoglobinuria, in both of which the hemoglobin is so altered by toxic agents that it becomes unavailable for oxygen transport, and thus of no respiratory value. Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock. Local stagnant hypoxia may be due to any condition that reduces or prevents the circulation of the blood in any area of the body. Examples include Raynaud disease and Buerger disease, which restrict circulation in the extremities; the application of a tourniquet to control bleeding; ergot poisoning; exposure to cold; and overwhelming systemic infection with shock. In histotoxic hypoxia the cells of the body are unable to use the oxygen, although the amount in the blood may be normal and under normal tension. Although
The Respiratory System
characteristically produced by cyanide, any agent that decreases cellular respiration may cause it. Some of these agents are narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents.
Altitude sickness, sometimes called mountain sickness, is an acute reaction to a change from sea level or other lowaltitude environments to altitudes above 2,400 metres (8,000 feet). Altitude sickness was recognized as early as the 16th century. In 1878 French physiologist Paul Bert demonstrated that the symptoms of altitude sickness are the result of a deficiency of oxygen in the tissues of the body. Mountain climbers, pilots, and persons living at high altitudes are the most likely to be affected. The symptoms of acute altitude sickness fall into four main categories: 1. respiratory symptoms such as shortness of breath upon exertion, and deeper and more rapid breathing; 2. mental or muscular symptoms such as weakness, fatigue, dizziness, lassitude, headache, sleeplessness, decreased mental acuity, decreased muscular coordination, and impaired sight and hearing; 3. cardiac symptoms such as pain in the chest, palpitations, and irregular heartbeat; and 4. gastrointestinal symptoms such as nausea and vomiting. The symptoms usually occur within six hours to four days after arrival at high altitude and disappear within two to five days as acclimatization occurs. Although most
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
people gradually recover as they adapt to the low atmospheric pressure of high altitude, some persons experience a reaction that can be severe and, unless they return to low altitude, possibly fatal. At higher altitudes, the air becomes thinner and the amount of breathable oxygen decreases. The lower barometric pressures of high altitudes lead to a lower partial pressure of oxygen in the alveoli, or air sacs in the lungs, which in turn decreases the amount of oxygen absorbed from the alveoli by red blood cells for transport to the body’s tissues. The resulting insufficiency of oxygen in the arterial blood supply causes the characteristic symptoms of altitude sickness. The main protection against altitude sickness in aircraft is the use of pressurized air in cabins. Mountain climbers often use a mixture of pure oxygen and air to relieve altitude sickness while climbing high mountains. In addition, the prophylactic use of the diuretic acetazolamide initiated two to three days before ascent may prevent or mitigate acute altitude sickness. A more serious type of altitude sickness, high altitude pulmonary edema (HAPE), occurs rarely among newcomers to altitude but more often affects those who have already become acclimated to high elevations and are returning after several days at sea level. In pulmonary edema, fluid accumulates in the lungs and prevents the victim from obtaining sufficient oxygen. The symptoms are quickly reversed when oxygen is given and the individual is evacuated to a lower area.
Barotrauma and Decompression Sickness
Barotrauma is any of several injuries arising from changes in pressure upon the body. Humans are adapted to live at an atmospheric pressure of 760 mm of mercury (the pressure at sea level), which differs from pressures experienced
in solution. lungs. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. sudden expansion of air trapped within the thorax can burst one or both lungs. or under the skin of the neck. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. and caisson workers are highly susceptible to the sickness because their activities subject them to pressures different from the normal atmospheric pressure experienced on land. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. sinuses. face. underwater divers. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. such as the ears. and these dissolved gases come
. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. Pilots of unpressurized aircraft.7
The Respiratory System
in underwater environments and in the upper atmospheres of space. When a pilot ascends to a higher altitude. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). small amounts of the gases that are present in the air. however. the pleural spaces. For example. such as the eardrum. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). the external pressures upon his or her body decrease. At atmospheric pressure the body tissues contain. 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. In certain cavities of the body. and torso. A fatal form of barotrauma can occur in submariners and divers. and intestines. there are air pockets that either expand or contract in response to changes in pressure.
The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. The pathogenesis of decompression sickness begins both with the mechanical effects of bubbles and their expansion in the tissues and blood vessels and with the surface effects of the bubbles upon the various components of the blood at the blood–gas interface. Shallow. the excess nitrogen is released. If the ascent is slow enough. the gases have time to diffuse from the tissues into the bloodstream. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. signals the onset of pulmonary decompression sickness. Therefore. Nitrogen is much more soluble in fatty tissue than in other types. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. Bubbles forming in the brain. The term bends is derived from this affliction. Conversely. the “chokes. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). The nervous system is composed of about 60 percent lipids. speech defects. spinal cord. pain is usually severe and mobility is restricted.” The major component of air that causes decompression maladies is nitrogen. When bubbles accumulate in the joints. often associated with a sharp retrosternal pain on deep inspiration.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
out of solution. and personality changes. as the affected person commonly is unable to straighten joints. When the pressure decreases. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s
. nausea. rapid respiration. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled. The gases then pass to the respiratory tract and are exhaled from the body. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). numbness.
and severe shock. During the descent. and the lung may collapse. 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). Because the lung tissue is elastic and interspersed with tubules and sacs of air.
Thoracic squeeze. If compression continues. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. and the size of the lungs decreases. a burning sensation while breathing.7
The Respiratory System
itches. but this process is not always able to reverse damage to tissues. the air inside the lungs is compressed. indicate nitrogen bubbles in the respiratory system.
. It most commonly occurs during a breath-holding dive underwater. while too little air causes compression and collapse of the lung walls. the lung shrinks to about one-fourth its size at the surface. Too much air causes rupture of lung tissue. The outer linings of the lungs (pleural sacs) may separate from the chest wall. an increase in pressure causes air spaces and gas pockets within the body to compress. or lung squeeze. Other symptoms include chest pain. is a type of barotrauma involving compression of the lungs and thoracic cavity. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. Usually these symptoms pass in 10 to 20 minutes. Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. Excessive coughing and difficulty in breathing. If one descends to a depth of about 30 metres (100 feet). known as the chokes.
Artificial respiration may be necessary if the breathing has stopped. or breathing—at the time of rescue. the oxygen deprivation that occurs with immersion in water was believed to lead to irreversible brain damage if it lasted beyond three to seven minutes. do not separate from the chest wall. although they lack evidence of life. even when reduced.000 metres (3. their lungs. having no measurable vital signs—heartbeat. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. and gives up the remaining tidal air in his or her lungs. It is now known that victims immersed for an hour or longer may be totally salvageable. The sperm whale is reported to dive to about 1.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The predominant symptom felt by the diver is pain when the pressure becomes too great. and their bodies are adapted to use the gases in the bloodstream more conservatively. Any symptoms of thoracic squeeze call for prompt medical attention.300 feet). the diver may have difficulty in breathing. which can be relieved by ascending. If the thoracic squeeze has been sufficient to cause lung damage.
Drowning is suffocation by immersion in a liquid. more than 10 times the depth that humans can tolerate. These aquatic mammals have been found to have more elastic chest cavities than humans. Animals such as seals and whales that descend to much greater depths than humans on a single breath of air have special adaptations to help them. There the heart may continue to beat feebly for a brief interval. pulse. and may even become unconscious. A fuller appreciation of the
. physically and intellectually. loses consciousness. Deprived of oxygen the victim stops struggling. usually water. Until recently. may exhale frothy blood. but eventually it ceases.
quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. The mechanism is powerful in children. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. A natural biological mechanism that is triggered by contact with extremely cold water. In this suspended state. known as the mammalian diving reflex.7
The Respiratory System
body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. so that many people who once would have been given up for dead are being saved. enhances survival during submersion. actual aspiration of water into the lungs may or may not occur.
. Actual arrest of circulatory processes is a relatively late development in the drowning sequence. When aspiration does occur. despite a total absence of respiratory gas exchange. the volume of fluid entering the lungs rarely exceeds a glassful. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. in other respects it performs normally. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. thus permitting seagoing mammals to hunt for long periods underwater. and surface areas of the body to the heart and the brain.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. abdomen. Scientists have determined that vestiges of the reflex persist in humans. Up to 15 percent of drownings are “dry. Even though the heart functions at a slower rate. Often. It diverts blood from the limbs. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents.
slows the heart rate. 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
In warm water the body’s need for oxygen is increased. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. and promotes unconsciousness.6 °F (17 °C) have survived. survival following hypothermic coma is almost 75 percent.
. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. None of these effects is imminently life-threatening. Such warmwater drownings occur commonly in domestic bathtubs.” “Lifeless” immersion victims with core temperatures as low as 62.
drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases.
recognizing the signs and syMptoMs of disease
The symptoms of lung disease are relatively few. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. have contributed to improvements in the diagnosis and evaluation of respiratory disease. many technological advances.CHAPTER7
APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT
he study of the anatomy. especially in the area of disease prevention. This expansion of scientific understanding has enabled important progress in respiratory medicine. Today. or respiratory medicine. particularly concerning techniques employing X-ray imaging or endoscopy. and pathology of the human respiratory system is known as pulmonology. In addition. Likewise. 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
. physiology. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree.
and tasks such as dressing cannot be performed without difficulty. It may become so severe as to immobilize the victim. as when a foreign body is inhaled into the trachea. such as walking up a flight of stairs. may also cause severe and unremitting dyspnea. it may also indicate the presence of inflammation. or a tumour. What is noted is a slowly progressive difficulty in completing some task. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. or shortness of breath. it is insidious in onset and slowly progressive. in which there is irreversible lung damage. but in diseases such as emphysema. commonly. it is constantly present. or walking uphill. particularly in the first two hours after awakening in the morning. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. or with the onset of a severe attack of asthma. playing golf. the lung capillaries become engorged. This sensation. Hemoptysis is also a classic sign of tuberculosis of the lungs. 30 to 60 ml of sputum are produced in a 24-hour period. and. resulting from occupational lung disease or arising from no identifiable antecedent condition. of complex origin. capillary damage. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. Although it may result simply from an exacerbation of an existing infection. and fluid may accumulate in
Approaches to Respiratory Evaluation and Treatment
malignant diseases of the major airways. Severe fibrosis of the lung. The shortness of breath may vary in severity. When this occurs. may arise acutely. The second most important symptom of lung disease is dyspnea. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. of which bronchitis is a common example. if the right ventricle that pumps blood through the lungs is functioning normally. More often.
or by a tumour that arises from the pleura itself. such as a mesothelioma. a condition known as a pleural effusion. pain of this severity is rare. which leads to acute congestion of the affected part. a small lung cancer that is not obstructing an airway does not produce shortness of breath.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). This is caused by narrowing of the airways. such as occurs in asthma. In addition.7
The Respiratory System
small alveoli and airways. diffuse
. for example. but it is most often associated with an attack of pneumonia. To these major symptoms of lung disease—coughing. of the toes) called “clubbing. A wheeziness in the chest may be heard. For example. severe chest pain may be caused by the spread of malignant disease to involve the pleura. The pain disappears when fluid accumulates in the pleural space. Some diseases of the lung are associated with the swelling of the fingertips (and. and chest pain—may be added several others. can cause pleurisy. It is commonly dyspnea that first causes a patient to seek medical advice. Chest pain may be an early symptom of lung disease. but absence of the symptom does not mean that serious lung disease is not present. rarely. Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. Fortunately. Severe. dyspnea. in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. 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. pulmonary embolism. since. 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.
as may sensory changes in the legs. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. cerebral signs from intracranial metastases. particularly the small nodes above the collarbone in the neck. Thus. Because the symptoms of lung disease.7 Approaches to Respiratory Evaluation and Treatment
fibrosis of the lung from any cause. may be diverse indicators of lung disease. A person with active lung tuberculosis or with lung cancer. Loss of appetite and loss of weight. In some lung diseases. In the case of lung cancer. for example. such as mild indigestion or headaches. a disinclination for physical activity. especially in the early stage. and lung cancer. general psychological depression. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints.
Methods of inVestigation
Physical examination of the chest remains important. Not infrequently. The generally debilitating effect of many lung diseases is well recognized. the patient may feel as one does when convalescent after an attack of influenza. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. as it may reveal the presence of an area of inflammation. this unusual sign may disappear after surgical removal of the tumour. unusual fatigue. Not infrequently. or seemingly minor symptoms as the first indication of disease. and some symptoms apparently unrelated to the lung. since a peripheral neuropathy may also be the presenting evidence of these tumours. the first symptom may be a swelling of the lymph nodes that drain the affected area. a
. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. may be conscious of only a general feeling of malaise. a hip fracture from bone metastases. are variable and nonspecific.
The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. In these techniques. and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds.7
The Respiratory System
pleural effusion. MRI is useful for imaging the heart and blood vessels within the
. or an airway obstruction. in the case of perfusion scanning. the lung tissue. While the resolution of computerized tomography is much better than most other visualization techniques. 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. in the case of ventilation scanning. The sounds detected with a stethoscope may reveal abnormalities of the airways. because the technique is not well suited to imaging air-filled spaces. percussion to gauge the resonance of the underlying lung. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. Methods of examination include physical inspection and palpation for masses. and the perfusion scan allows visualization of the blood vessels in the lungs. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. a radioactive tracer molecule is either inhaled. sputum examination for malignant cells is occasionally helpful. and abnormal breathing patterns. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). or injected. or the pleural space. The ventilation scan allows visualization of gas exchange in the bronchi and trachea.
the stiffness of the lung. Tests of exercise capability. More complex laboratory equipment is necessary to measure the volumes of gas in the lung. trachea. By feeding a surgical instrument through a special channel of the bronchoscope.
. and major bronchi. airflow resistance. Ventilatory capability can be measured with a peak flow meter. and the rate of gas transfer across the lung. or the pressure required to inflate it. in which workload. the measurement of the rate and quantity of air exhaled forcibly from a full respiration. are useful in assessing functional impairment and disability. the distribution of ventilation within the lung. total ventilation. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. and after exercise. and gas exchange are compared before. which is often used in field studies. during. which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. Spirometry.7 Approaches to Respiratory Evaluation and Treatment
thorax. physicians can collect fluid and small tissue samples from the airways. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function.
or the transfer of gas between the alveoli and the blood. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs). David McNew/Getty Images
Pulmonary Function Test
A pulmonary function test is a procedure used to measure various aspects of the working capacity and efficiency of the lungs and to aid in the diagnosis of pulmonary disease.7 The Respiratory System
A spirometry test measures lung capacity and degree of airflow obstruction. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. and (2) those measuring respiratory function. Tests of ventilatory function include the following measurements: residual
or air within the chest at the end of a quiet expiration. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. 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. include maximal voluntary ventilation (MVV). the resting lung volume. Except for the residual volume.7 Approaches to Respiratory Evaluation and Treatment
volume (RV). functional residual capacity (FRC). which measure the capacity of the lungs to move air in and out. tidal volume. maximal flow rate of a single expelled breath. vital capacity. maximum air volume expelled in a time interval. air remaining within the chest after a maximal expiration. who discovered X-rays in 1895. all the other volumes may be recorded with a spirometer. forced expiratory volume (FEV). and total lung capacity (TLC).
X-ray imaging is a valuable diagnostic technique used in medicine. air volume within the chest in full inspiration. Ventilation tests. volume of a breath. which is measured by a dilution method. expressed in litres of air per minute. One of the most common screening roentgenograms is the chest film. This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. of the lungs. The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. or capillaries. and maximal expiratory flow rate (MEFR). taken to look for infections such as
. maximum air volume that can be expelled after a maximum inspiration. maximal air volume expelled in 12 to 15 seconds of forced breathing. breathing movements may also be registered graphically on a spirogram.
Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. To track the movement of air. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled
. unfortunately. or VQ (ventilation quotient) scan. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. 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 blockage of one of the pulmonary arteries or of a connecting vessel. For the perfusion part of the scan. 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. thereby narrowing the passageway and hindering the flow of blood. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs. but. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism.7
The Respiratory System
tuberculosis and conditions such as heart disease and lung cancer. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue.
Lung Ventilation/Perfusion Scan
A lung ventilation/perfusion scan. This approach may be taken for patients with advanced or rapidly spreading lung cancer. 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.
In general. the levels of radioactivity are exceptionally low and pose a very small risk to patients. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism. a mismatch between the two scans is indicative of disease.7 Approaches to Respiratory Evaluation and Treatment
with technetium). The appearance of hot spots. persons for whom the scanning procedure is not recommended include women who are pregnant or who are breast-feeding. Depending on whether a dark area appears in a ventilation scan or in a perfusion scan. In contrast. or areas where the tracers become highly concentrated and therefore produce bright areas in the images. In both ventilation and perfusion scans. and another set of images is taken with the scanner. normal air and blood flow are reflected in the even distribution of tracers within the lungs. the tissues affected will be either oxygen. Nutrient deprivation renders the tissue highly susceptible to death. he or she may subsequently undergo more invasive procedures.or blooddeprived. Although the tracers used in lung ventilation/perfusion scanning are radioactive.
Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. the ventilation and perfusion scans match for a person with healthy lungs. highlight places within the lungs where air or blood have accumulated abnormally. Thus. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent
. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. including angiography.
Inc. Encyclopædia Britannica.
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The trachea and major bronchi of the human lungs.
to deliver certain therapeutic agents directly into the lungs.7 Approaches to Respiratory Evaluation and Treatment
cough or who are coughing up blood.
. 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. Flexible scopes. In addition. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. and to assist in the placement of stents (tubes. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. blood) to be removed during an examination. The latter feature is commonly employed for biopsy—the collection of tissues for histological study. There are two types of bronchoscopes. which enables large volumes of fluid (e. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. known as a rigid bronchoscope.. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs. both flexible and rigid scopes have a channel through which instruments can be passed. Bronchoscopy is also employed to remove foreign objects from the airways. 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. consists of a metal tube that has a wide suction channel. they remain superior for specific applications.g. because of their ability to bend and twist. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways. The second type of scope.
the movement of a bronchoscope through the airways often scratches superficial tissues. there are several important risks associated with the bronchoscopy procedure itself. upon waking. Because the region of the mediastinum contains the heart.7
The Respiratory System
Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. however. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. Bleeding is especially common following biopsy. In most cases. including nausea and vomiting. In contrast. In addition. which can cause side effects in some people. which occurs when the instrument is not sanitized properly. as well as a set of lymph nodes. mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. bleeding subsides without the need for medical intervention. because of the discomfort caused by the device. and thymus gland. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity.
Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. necessitates the use of general anesthesia. trachea. causing a condition known as pneumothorax. esophagus. causing them to bleed. rigid bronchoscopy. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs. For example. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). serving as one of the primary
light-emitting. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. Severe complications— such as bleeding. particularly for cellular defects associated with cancer and for the presence of infectious organisms. Staging involves the investigation of cells to assess the degree to which cancer has spread. Most patients recover within several days following mediastinoscopy. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. In cancer staging. including computerized axial tomography and positron emission tomography. A mediastinoscope—a thin. This step of the procedure is known as mediastinotomy.
. During mediastinoscopy. The biopsy samples are then investigated for evidence of abnormalities. By carefully maneuvering the scope in the space. a surgeon first makes a small incision in the patient’s neck. This may also be performed for other tissues in the region that display signs of disease. infection. flexible instrument—is then passed through the incision and into the space between the lungs. the doctor is able to investigate the surfaces of the various structures.7 Approaches to Respiratory Evaluation and Treatment
methods by which tissue samples are collected from the mediastinal lymph nodes for the staging of lung cancer. immediately above the sternum. such as abnormal growths or inflammation. and the procedure is associated with a very low risk of complications. which is performed under general anesthesia. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues.
performed manually or by means of a handheld percussor or vest. mucolytics. such as bronchodilators. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. as in treatment of cystic fibrosis. A mixture of helium and oxygen is used to treat some diseases of airway obstruction. There are different methods of treatment employed in respiratory therapy.
. respiratory therapists are experts in the setup. Oxygen may be administered in controlled amounts to assist laboured breathing. One of the conditions frequently dealt with is obstruction of breathing passages. and antibiotics. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. or a fog (as in an oxygen tent or a croup tent). Medications. In addition. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm. Chest percussion. Therapy may involve the administration of gases for inhalation. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. and maintenance of mechanical ventilators.7
The Respiratory System
types of respiratory therapy
Respiratory therapy is primarily concerned with assisting or improving the respiratory function of individuals with acute or chronic lung disease. 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. hot steam. produces vibrations that help to loosen and mobilize secretions. each of which may be tailored to a specific disease. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. adjustment.
The constricting action chiefly affects the smallest arteries. they mimic the effects of stimulation of the sympathetic
. and larger arteries respond to some degree. and antibiotics. thus reducing blood flow to the inflamed areas. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. The relative safety and efficacy of these drugs has made them generally reliable medications. that are of particular importance in the routine treatment of respiratory illness. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. When administered in nasal sprays or drops or in devices for inhalation. decongestants and antihistamines are available over the counter.7 Approaches to Respiratory Evaluation and Treatment
There are many different types of drugs that may be used in the treatment of respiratory diseases. decongestants. Decongestants are sympathomimetic agents. That is. antihistamines. veins. although capillaries. there are three groups. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. However. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. and thus they are used by many people. In countries such as the United States. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. due to the emergence of resistant organisms. the arterioles. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides.
an alkaloid originally obtained from the leaves of ma huang. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. inflammation. results in absorption into the bloodstream. thereby preventing histaminetriggered reactions under such conditions as stress. which has been used in Chinese medicine for more than 5.7
The Respiratory System
division of the autonomic nervous system. Ephedrine and other decongestants are made by chemical synthesis. 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. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. any of several species of shrubs of the genus Ephedra. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of
. They include phenylephrine hydrochloride. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. and naphazoline hydrochloride. The oldest and most important decongestant is ephedrine. dizziness. or heart palpitations. causing anxiety. One of the chief drugs of the group is epinephrine. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. amphetamine and several derivatives. they must be used repeatedly. too frequent use.000 years. headache. in which epinephrine constricts the blood vessels of the skin. Because none of them has a sustained effect. insomnia. however. and allergy.
The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. More than 100 antihistaminic compounds soon became available for treating patients. In 1942. If a patient’s condition does not improve after three days of treatment with antihistamines. and dryness of the mouth. Nasal irritation and watery discharge are most readily relieved. tested later and found to be more potent. Anilinetype compounds. subsequently. nearly all antihistamines produce undesirable side effects. antihistamines can control certain allergic conditions. Antihistamines are readily absorbed from the alimentary tract. The most common side effect in adults is drowsiness. Persons with urticaria. were too toxic for clinical use. Used in sufficiently large doses. itching. among them hay fever and seasonal rhinitis. blurred vision.
. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. headache. and most are rendered inactive by monoamine oxidase enzymes in the liver.7 Approaches to Respiratory Evaluation and Treatment
histamine except those on gastric secretion. and less toxic were prepared. more specific. The development of these antihistamines dates from about 1937. it is unlikely that he or she will benefit from them. compounds that were more potent. and certain sensitivity reactions respond well. Other side effects include gastrointestinal irritation. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. edema. Antihistamines are not usually beneficial in treating the common cold and asthma. The first antihistamines were derivatives of ethylamine.
are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin. but they can be given parenterally. which inhibit bacterial protein synthesis. Some are highly specific. Macrolides.g. and they are especially important in the treatment of bacterial respiratory infections. Antibiotics vary in their range of action.. Antibiotics known as macrolides (e. Compounds of this class suppress histamine-induced gastric secretion and have proved extremely useful in treating gastric and duodenal ulcers. clarithromycin. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive. They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). at a high enough concentration to be effective (but not cause side effects). the bacillus responsible for diphtheria.7
The Respiratory System
During the 1970s an H2-blocking agent. whereas others. erythromycin. Oxygen therapy is used for acute conditions. such as the tetracyclines. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era. Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae.
The medical administration of oxygen is an important means of treating respiratory disease. act against a broad spectrum of different bacteria. cimetidine (Tagamet) was introduced. azithromycin) are particularly effective in the treatment of bacterial respiratory infections. in which tissues such as the
. and for a sufficient length of time to ensure that the infection is totally eradicated. These drugs are usually administered orally.
however. because the procedure can potentially stimulate the generation of DNA-damaging free radicals.7 Approaches to Respiratory Evaluation and Treatment
brain and heart are at risk of oxygen deprivation. Some patients may require oxygen administration via a transtracheal catheter. oxygen may be delivered through a face mask or through a nasal cannula. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. HBOT has been promoted as an alternative therapy for certain conditions. 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. For patients affected by chronic lung diseases. Another form of therapy. portable compressed-gas oxygen cylinder. In both the hospital and the home settings. known as hyperbaric oxygen therapy (HBOT). oxygen may be administered by citizen responders via mouth-to-mouth breaths in cardiopulmonary resuscitation (CPR) or by emergency medical personnel via a face mask placed over the victim’s mouth and nose that is attached to a small.
. as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). In addition. These applications are controversial. which is inserted directly into the trachea by way of a hole made surgically in the neck. a device inserted into the nostrils that is connected by tubing to an oxygen system. 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. In emergency situations. such as chronic obstructive pulmonary disease (COPD). home oxygen therapy may be prescribed by a physician.
provide a method of storing oxygen at concentrations greater than that occurring in ambient air. In the ABG test. which can be refilled at pharmacies or by delivery services. it is converted to a gas. Oxygen is usually administered in controlled amounts per minute. Two tests that are commonly used to assess the concentration of oxygen in the blood include the arterial blood gas (ABG) test and the pulse oximetry test. 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. which necessitates more-frequent cylinder replacement. In pulse oximetry. The stored oxygen can then be used by the patient when needed and is readily replenished. Flow rate is determined based on measurements of a patient’s blood oxygen levels. Another form of oxygen storage is in compressed-gas cylinders. Oxygen turns to liquid only when it is kept at very cold temperatures. and carbon dioxide levels are measured. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood
. Large stationary and small portable gas cylinders can be used in the hospital or the home.7
The Respiratory System
There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. oxygen. Oxygen concentrators. and blood acidity. which draw in surrounding air and filter out nitrogen. Stationary and portable oxygen concentrators have been developed for use in the home. Liquid oxygen can be stored in small or large insulated containers. a probe. Oxygen also can be stored as a highly concentrated liquid. as opposed to releasing gas constantly. When it is released under pressure from cold storage. generally placed over the end of a finger. 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. a measure known as the flow rate. blood is drawn from an artery.
Excess oxygen flow also can result in conditions such as barotrauma. Also.7 Approaches to Respiratory Evaluation and Treatment
that are carrying oxygen. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. such as with the drug bleomycin. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. Bronchopulmonary dysplasia. it does not appeal to some patients. a chronic disorder affecting infants. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. HBOT is associated with an increased risk of barotrauma of the ear. For example. In general. oxygen therapy does not alter the progression of lung disease. if they are not secured and stored
. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD. Compressed-gas cylinders present a significant safety hazard in the home as well. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. For example. adverse physiological effects may ensue if the flow rate is too high. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. a response that is amplified in the presence of excess oxygen. leading to the damage of healthy tissues. Likewise. However. If oxygen flow rate is too low. which can lead to tissue dysfunction and cell death.
Such techniques. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. The person using mouth-to-mouth breathing places the victim on his back. they may cause explosions. carbon monoxide poisoning. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1.
. Furthermore. clears his mouth of foreign material and mucus. candles. oxygen can readily spread fire. suffocation. strangulation. choking. Likewise. or other sources of ignition. throat. establishing and maintaining an open air passage from the upper respiratory tract (mouth. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial.
Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. lifts the lower jaw forward and upward to open the air passage. can prevent some deaths from drowning. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. and electric shock. and pharynx) to the lungs and 2. if applied quickly and properly. which has been found to be more effective than the manual methods used in the past.7
The Respiratory System
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.7 Approaches to Respiratory Evaluation and Treatment
Mouth-to-mouth breathing is the most effective means of manual artificial respiration.
the results of chest percussion and imaging tests. tumours. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. For diagnostic applications. liver. such as tuberculosis and pneumonia.7
The Respiratory System
and clamps the nostrils. including the lungs. including infectious organisms. particles such
. He then alternately breathes into the victim’s mouth and lifts his own mouth away. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. such as chest X-rays or computerized axial tomography chest scans. the rescuer may cover both the victim’s mouth and nose.
Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. It is most often used to diagnose the cause of pleural effusion. In the subsequent thoracentesis procedure. including pleural empyema. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. If the victim is a child. Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion. permitting the victim to exhale. 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. and lung infections. and spleen. including heart failure. as well as to prevent further complications associated with the condition. Once the needle is inserted. Prior to thoracentesis. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs.
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. More serious complications include pneumothorax.e.7 Approaches to Respiratory Evaluation and Treatment
as asbestos. another breathing mixture. However. generally lasting about 10 to 15 minutes. and aberrant stimulation of the vasovagal reaction.. particularly upon detection of cancerous cells. and wounds that are difficult to heal. also known as a decompression chamber (or recompression chamber). and tumour cells.
A hyperbaric chamber. tissue injury arising from radiation therapy for cancer. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. the accumulation of air in the pleural space. carbon monoxide poisoning. for several hours afterward patients are often observed for the manifestation of adverse effects. Minor complications associated with thoracentesis include pain and cough. coagulopathy). gas gangrene resulting from infection by anaerobic bacteria. The results of these analyses frequently warrant further diagnostic testing. Thoracentesis is contraindicated in persons with bleeding disorders (i. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks. Experimental compression chambers first came into use around 1860. Pressures
. In its simplest form. which occurs when a needle punctures the lungs. gas embolism. leading to a drop in blood pressure and fainting (syncope). Air. which are suggestive of mesothelioma or lung cancer. Thoracentesis is a relatively quick procedure.
a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues. In the treatment of carbon monoxide poisoning. In the treatment of decompression sickness. 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
A hyperbaric chamber creates a high-pressure environment. the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. which increases oxygen availability to the body in therapeutic treatment. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). Chris McGrath/ Getty Images
used for medical treatment are usually 1. or from a combination of the two. for example.
pulmonary fibrosis. many people who die of severe head injuries. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. the techniques are being pursued aggressively in specialized centres. With proper selection of donor organs and proper transplantation technique. Because transplantation offers the only hope for persons with severe lung disease. sarcoidosis. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. 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. Persons severely disabled by cystic fibrosis. but from the late 1970s bilateral lung transplantation had some striking results. Availability of donor lungs is sharply limited by the number of suitable donors. who may be relatively young.
In the 21st century. survival at one year has been reported at 90 percent. which presumably would leave the lungs intact.7 Approaches to Respiratory Evaluation and Treatment
Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. often have also suffered lung injury or lung infection. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. emphysema. 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
. for example.
Such progress promises to reduce the global mortality of lung cancer. Influenza viruses circulate globally. with health and environmental concerns at the forefront.
. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. mesothelioma. In many countries. in 2009 researchers reported having mapped the genetic codes of rhinoviruses. For decades. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. 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. basic knowledge of the viruses that cause the common cold eluded scientists.7
The Respiratory System
respiratory system. acquiring genetic mutations that alter their infectious characteristics. which are the most frequent cause of the common cold. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. In fact. The negative influence of behaviours such as tobacco smoking on lung function is now well documented. sometimes drastically increasing their ability to infect and cause disease in humans. However. and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. and similar preventable respiratory afflictions. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases.
As researchers and physicians continue to uncover new information about the human respiratory system. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. 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. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests.7 Approaches to Respiratory Evaluation and Treatment
Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease. For example. as well as new treatments. In addition. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities.
leaf-shaped flap. epiglottis Cartilaginous. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. Act on the larynx as a whole. moving it upward or downward. controls the traffic of air and food. glottis A sagittal slit formed by the vocal cords. functions as a lid to the larynx and. convection The transfer of heat by movement of a heated fluid such as air or water. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. or transformation of glucose into energy. during the act of swallowing. glycolysis Fermentation. hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment.
. hypercapnia Excess carbon dioxide retention. hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange.GLOSSARY
apnea Cessation of breathing. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. Also known as a decompression chamber or recompression chamber.
when added to a liquid. length. thrombus Clot that forms in the blood vessel and remains at the point where it was formed. thereby increasing its spreading and wetting properties. paranasal sinuses Cavities in the bones that adjoin the nose. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. a thin membranous sac encasing each lung. reduces its surface tension. resulting in the development of secondary tumours. sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. neuraminidase A glycoprotein on the surface of influenza viruses. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. and tension of the vocal cords. rhinitis Inflammation of the mucous tissue of the nose.
hypoxia Reduction of oxygen supply to tissues to less than physiological levels. purulent Pus-producing. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. pleura In humans. surfactant Substance that. metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. and as the organ of phonation. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung.
Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. a detailed text on impairment of lung function caused by disease. 4th ed. Berger. (1995). Control of breathing is described in Murray D. Bennett and David H. and Michael P.BIBLIOGRAPHY
Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. Dempsey and Allan I. Macklem. Fraser et al. Fishman’s Pulmonary Diseases and Disorders. 4th ed. Christie. Fishman and Jack A.. Control of Breathing in Health and Disease (1999). Sullivan (eds. (1988). Murray. 4th ed. 2nd ed. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. The Physiology and Medicine of Diving. (2008). 1 also available in a 3rd ed. ed. and Robert G. Bates. 2nd ed. (1977–79). with vol.
. The Respiratory System (2003). (1971).). H. Peter T. (1995). Diagnosis of Diseases of the Chest. Physiology of Respiration. The human respiratory system is described in David V. 2nd ed. (1993). and Ronald V. 2nd. Saunders and Colin E.). Altose and Yoshikazu Kawakami (eds. Sleep and Breathing. and Jerome A. Pack (eds. (2001). Abnormal breathing during sleep is covered by Nicholas A.). 2nd ed. 4 vol. Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. Corwin Hinshaw and John F. Elliott (eds. Hlastala and Albert J.. The effects of swimming and diving on respiration are detailed in Peter B. Elias. HighAltitude Medicine and Pathology.). Regulation of Breathing. (1994).
(1980). 2nd ed.
. (2005). Fishman (ed. Weinberger. Respiratory Disorders (1983). Principles of Pulmonary Medicine.7 Bibliography
Diseases of the Chest. 2nd ed. provides a comprehensive overview of pathophysiology as related to clinical syndromes. G. Steven E. Pulmonary Diseases and Disorders. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. 3rd ed. (1981). Scientific Foundations of Respiratory Medicine (1981). Semple. 3 vol.). Alfred P. Murray and Jay A. (1998). (1994). Disorders of the Respiratory System. and Ian R. John Crofton and Andrew Douglas. (eds. Respiratory Diseases. 2nd ed. 3rd ed. 4th ed. and Andrew M. Bateman. See also John F. Comprehensive texts include Gordon Cumming and Stephen J. Textbook of Respiratory Medicine. Thurlbeck’s Pathology of the Lung. Nadel (eds. (1980).).). 3rd ed. see also J. Churg et al. Scadding and Gordon Cumming (eds.). Cameron and Nigel T.. (1988). is a general textbook covering diagnosis and treatment of chest diseases.
117. 51. 176. 103 anemia. 77 Agricola. 48 apnea. 208. 52.130–131. 110. 160–164. 86. 169 lung. 171. 184. 33–34 stem. 164. 198. 168–169. 111. 187 byssinosis. 169. 188–189 alveoli. 52. 93. 73. 75 acidosis. 126 arterial gas embolism. 109. 186. 134. 91. 46. 42. 174–175
cancer. 38. 81. 28–29 bronchiectasis. 171 antibiotics. 35. 213 atelectasis. 131. 131–133. 188 bird fancier’s lung. 30. 49 bronchi. 175. 198 bronchioles. 127. 115. 166 black lung. 217 Bert. 168. 124–125. 74. 111. 172. 106 bradykinin. 27 adenosine triphosphate (ATP). 169. 107. 196. structure and function of. Josef. 170–171 Bordet. 112–113. 218–220 asbestos. 50 Breuer. 136. 79–80. 159. 135. 100–102. 75. 99–100. 193 anthracosis. 94. 197. 81. 194 asthma. 175. 129. 103. 137. 114. 116. 171–173 asphyxiation. 173. 174 Buerger disease. 184–186 altitude sickness. 187 anesthesia. Paul. 152–156. 217 bronchoscopy. 64. 118–119 air–blood barrier. structure and function of. Jules. 96. 152. 171 AIDS. 169. 147. 153.
. 85 artificial respiration. 171–173. 181. 102. 223 bronchitis. 152. 127. structure of. Georgius. 209 animals. 210. 30. 184 Actinomyces. 221 asbestosis. 214 antihistamines. 182. 159. 34–35 amantadine. 97. 76. 46. 122. 211. 111 Adam’s apple. 123. 197 bronchopulmonary dysplasia. structure of. 30. 39 alcoholism. 33–34 bronchiolitis. 137. 108. 141–144
barotrauma. 205–208 brown lung. 92.INDEX
acid–base balance. 189–192. 212–214 aortic body. 113 alkalosis. 211.
160 HIV. 129. 88–91. 96. 127–129. 25. 69–72 Gengou. 64. 221 cardiopulmonary resuscitation (CPR). 56. 105–106. 211. 130. 46. 214 diving. 62. 80. 98–99 epiglottitis. 75–78. 198. 183. 182. 49 high altitudes. 218 dyspnea. 156–158. 132 types of. 190. 44. 88 corticosteroids. Ewald. 102. 197. 164 coughing blood. 122. 50. 196–197. 215. 135. 216–217 Hering. 132. 207 physiology of. 106. 183 hay fever. 65. 213 hemoglobin. 204. 49 Hering-Breuer reflex. 30. 198 croup. 50. 50. 64. 210. 221. 182
gas exchange. 79–81. 157–158. 149. 47. 222 decongestants. 122. 47. 223
emphysema. 177. 106. 187. 91. 158. 170. 65. 188–189. 67. 58–59. 201. 190 histamine. 81–86. 138. 215. 80. 98–99 epinephrine. 98–99 cystic fibrosis. 220. 87. 67 chronic obstructive pulmonary disease (COPD). 78. 189–192. 168. 133–136. 48. 137. 196. 52 Cheyne-Stokes breathing. 81. 175. 98. 94. 143. 112. 217 Clara cells. 47. 98. 174. 122. 166 fungi. 81 central nervous system disease. 72 diphtheria. 159. 51–52. 191–193 drowning. 60. 95. 85. 86. Octave. 95. 147. abnormal. 171. 69. 223 eosinophilic granuloma. 21. 130. 115. 156. 209. 145–148. 97. 130. 197–198
Haldane. 25. 94. 119
. 213 cause of. 190. common.7 Index 181. 161. 27. 30 Goodpasture syndrome. 137. 159. 111. 75. 186. 131. 180. 192. 66. 164. 151
decompression sickness. 212 exercise (training). 136. 215 carotid body. 108. 78. 84. 136–138. 193–195. 106 glycolysis. John Scott. 117. 201
farmer’s lung. 158 diffusion limitation. 183. 98. 145. 187. 93. 87. 52 chloride shift. 197. 150 epiglottis. 184. 211–212 diaphragm. 63. 199. 137. 34 cold. 74 goblet cells. 84. 92. 144.
81 mucoviscidosis. 87. 199 bird flu. 144–145. 81 mountain sickness. 139. 128. 221 collapse of. 127 hygiene. 186–188
idiopathic pulmonary fibrosis. 102–105. 51–52. 95–96 larynx. 163 hydrothorax. 49. 159 congestion of. 156–158. 129. 182. 190. 169. 104 vaccine. 143. 44. 221–222 hypercapnia. 68. 50 meningitis. 52. 204. 196 laryngitis. 149 influenza. 110. René-ThéophileHyacinthe. 178. 46–48. 199. 69. 221 metabolism. 92. 96. structure and function of. 147. 26. 125 hypoventilation. 176. 138. 103 H1N1. 184–186 hypothyroidism. 141. 152–156. 99. 81–82. 93. 172. 223 lung ventilation/perfusion scan. 138. 88. 150. 208–209 mediastinum. 145
kidney. 198. 173. 178. 99 mediastinoscopy. 204–205
measles. 113–114. 217 hypoxia. 138–141. 215. 149. 78 anaerobic. 117. 45. 215. 47. 41. 166–167 hyperventilation. 98. 83 hypersensitivity pneumonitis. 122. 127. 119 hyperbaric chamber. 50. 209. 184
cancer of. 181. 103. 81 aerobic. 198. 214 leukemia. 83. 38. 76 Monge disease. 38–40 infarction. 177 size of. 126 hypoxemia. 26
. 73–78. 114. 74. 31. 110. 100 lungs
nephritis. 114–115. 135–136. 167. 31 transplantation of. 94. 208 medulla. 55–56. 91. 26–28 Legionnaire disease. 151. 87. 171–173. 197 development of. 94 nerves laryngeal. 117 mesothelioma. 173. 127. 37. 76–77. 149.7
The Respiratory System
hookworm. 74. 70.
170. 220 pleurisy. 108. 122. 130. 209. 172. 99
obesity. 198. 110 pulmonary alveolar proteinosis. 91. 198. 214 pertussis. 91. 214. 136
. 107 penicillin. 94. 211. 136. 214–218
128. 211. 87. 34 pyothorax. 95 shunting. 113. 41. 137 oxygen therapy. 180. 124. 88. 125. 138. 128. 31–32. 173. 189.7 olfactory. 126. 208. 87. 111 parrot fever. 194 pulmonary parenchyma. 126–130. 52–53. 184. 26. 85 nose cilia. 117. 33. 141. 104 osteoporosis. 91. 47 vagus. 149–150. 168–169. 127. 88 rimantadine. 85. 164 pharyngitis. 137. 104–105 respiratory distress syndrome. 36. 108. 198 pneumoconiosis. 38. 106. 167. 56. 127–129. 92. 23–24 sinus. 220 pneumothorax. 131. 155. 114 Pott disease. 198 pleural effusion. 154. 203
parasites. structure and function of. 93. 118 prostaglandins. 107–108. 128
Relenza. 93 sinusitis. 107. 53. 187 rheumatic fever. 103. 126. 160 sleep.
sarcoidosis. 50 psittacosis. 89 structure and function of. 21–24. 100 rhinoviruses. 114. 139. 44 Pontiac fever. 150–151 pulmonary edema. 69–71 silicosis. 93 congestion of. 50 nitrogen narcosis. 91–92. 105–106. 107. 92. 221 pollution. 164 inflammation of. 57. 103. 22. 103 Röntgen. 122 function of. 33. 170 pneumonia. 200. 84. 178. 169–170 sinuses. 223 scarlet fever. 159. 19. 50. 179–180 Reynaud disease. 139. 92–94. 95. 214 pharynx. 208. 127. 103. 108–113. 129–130.Wilhelm Conrad. 180–182 pons. 126 oseltamivir. 146. 152. 22 irrigation of. 87. 24–25 pickwickian syndrome. 179 rheumatoid arthritis. 126 pleura. 45.
The Respiratory System
smallpox. 163. structure and function of. 109. 102. 99. 91 vocal chords. 106 thoracentesis. 136. 58 ventilation–blood flow imbalance. 114–121. 92. 118. 94 smoking. 122. 95.102. 94 staphylococci. 105–107
zanamivir. 123–124 sore throat. 183. 130. 111. 99. 92 streptococcal bacteria. 129. 56. 96–98 trench mouth. 88. 87. 103. 197. 130. 175. 138. 218 sneezing. 170. 107. 104 tetanus. 128. 103. 133–135. 106. 176. 91. 95. 97. 164. 21. 91. 108. 27–28
Tamiflu. 199. 53. 150. 92. 220 typhoid. 25. 125. 94–95 tonsils. 97 smell. 124
whooping cough. 138. 96. 87. 214 surgery. 123. 220–221 thoracic emphyema. 93. 164 snoring. 208. 69 vestibular folds. 23–24. 97. 27–28 vitamin C. 97. 94. 33. 119. 164. 182. 78. 137. 53. 91. 116. 143. 171. 28–30 tracheitis. 204. 178. 171. 199. 87. 127–129 thoracic squeeze. 110. 172. 152. 97
vaccination. 131–132. 155–156. 95 tuberculosis. 198. 103. 209 swimming. 173 Valsalva maneuver. 92. 94–95. 93. 153. 92. false. 104–105
. 95. 81–86 syphilis. 92. 97. 122. 138. 96. 97
trachea. 192–193 tonsillitis. 146 strep throat.