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Editorial Technologies Lisa S. Luebering: Senior Manager Marilyn L.Published in 2011 by Britannica Educational Publishing (a trademark of Encyclopædia Britannica. 196. 226. © www. Chip Somodevilla/Getty Images On pages 19. All rights reserved. Copyright © 2011 Encyclopædia Britannica. 122. First Edition Britannica Educational Publishing Michael I.E. Distributed exclusively by Rosen Educational Services. cm. Inc. 60.” Includes bibliographical references and index. Kara. and the Thistle logo are registered trademarks of Encyclopædia Britannica. 230: A healthy set of lungs is the powerhouse behind the respiratory system. call toll free (800) 237-9932. Cover Design Introduction by Amy Miller Library of Congress Cataloging-in-Publication Data The respiratory system / edited by Kara Rogers. Biomedical Sciences Rosen Educational Services Heather M. Rosen Educational Services materials copyright © 2011 Rosen Educational Services. New York. Braucher: Senior Producer and Data Editor Yvette Charboneau: Senior Copy Editor Kathy Nakamura: Manager.(The human body) “In association with Britannica Educational Publishing. Media Acquisition Kara Rogers: Senior Editor.istockphoto. 87. 41.R467 2011 612.com / Sebastian Kaulitzki On page 10: Singing is one of many common activities that requires dynamic breath control. Inc.) in association with Rosen Educational Services. Rosen Educational Services. Respiratory organs—Popular works. Levy: Executive Editor J. 159.istockphoto. Moore Niver: Editor Nelson Sá: Art Director Cindy Reiman: Photography Manager Matthew Cauli: Designer. -. 228. I. Britannica. Inc. © www. NY 10010. LLC 29 East 21st Street. Rogers. Barton: Senior Coordinator. For a listing of additional Britannica Educational Publishing titles. Encyclopædia Britannica. ISBN 978-1-61530-147-8 (library binding) 1.com / nicoolay .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. Production Control Steven Bosco: Director. LLC. p. All rights reserved. QP121.
and Nerves 36 Lung Development 38 Chapter 2: Control and Mechanics of Breathing 41 Control of Breathing 41 Central Organization of Respiratory Neurons 44 Chemoreceptors 46 Peripheral Chemoreceptors 46 Central Chemoreceptors 48 Muscle and Lung Receptors 49 Variations in Breathing 50 Exercise 51 Sleep 52 32 43 51 .CONTENTS Introduction 10 Chapter 1: Anatomy and Function of the Human Respiratory System 19 The Design of the Respiratory System 19 Morphology of the Upper Airways 21 The Nose 21 The Pharynx 24 Morphology of the Lower Airways 25 The Larynx 26 The Trachea and the Stem Bronchi 28 Structural Design of the Airway Tree 29 The Lungs 31 Gross Anatomy 31 Pulmonary Segments 33 The Bronchi and Bronchioles 33 The Gas-Exchange Region 34 Blood Vessels. Lymphatic Vessels.
and Metabolism 73 Adaptations 78 High Altitudes 79 Swimming and Diving 81 Chapter 4: Infectious Diseases of the Respiratory System 87 Upper Respiratory System Infections 88 Common Cold 88 Sore Throat 91 Pharyngitis 91 Sinusitis 92 Tonsillitis 94 Lower Respiratory System Infections 95 Laryngitis 95 Tracheitis 96 Croup 98 Infectious Bronchitis 99 Bronchiolitis 100 Influenza 102 Whooping Cough 105 77 . Circulation.61 The Mechanics of Breathing 53 The Lung–Chest System 55 The Role of Muscles 56 The Respiratory Pump and Its Performance 57 Chapter 3: Gas Exchange and Respiratory Adaptation 60 Gas Exchange 60 Transport of Oxygen 63 Transport of Carbon Dioxide 65 Gas Exchange in the Lung 68 Abnormal Gas Exchange 69 Interplay of Respiration.
Psittacosis 107 Pneumonia 108 Legionnaire Disease 113 Tuberculosis 114 Chapter 5: Diseases and Disorders of the Respiratory System 122 Disorders of the Upper Airway 122 Snoring 123 Sleep Apnea 124 Pickwickian Syndrome 126 Diseases of the Pleura 126 Pleurisy 127 Pleural Effusion and Thoracic Empyema 127 Pneumothorax 129 Diseases of the Bronchi and Lungs 130 Bronchiectasis 130 Chronic Bronchitis 131 Pulmonary Emphysema 133 Chronic Obstructive Pulmonary Disease 136 Lung Congestion 138 Atelectasis 141 Lung Infarction 144 Cystic Fibrosis 145 Idiopathic Pulmonary Fibrosis 149 Sarcoidosis and Eosinophilic Granuloma 149 Pulmonary Alveolar Proteinosis 150 Immunologic Conditions of the Lung 151 Lung Cancer 152 Diseases of the Mediastinum and Diaphragm 156 115 123 .
165 167 181 Chapter 6: Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 159 Allergic Lung Diseases 159 Asthma 160 Hay Fever 164 Hypersensitivity Pneumonitis 166 Occupational Lung Disease 167 Silicosis 169 Black Lung 170 Asbestosis and Mesothelioma 171 Respiratory Toxicity of Glass and Metal Fibres 173 Byssinosis 174 Respiratory Toxicity of Industrial Chemicals 175 Disability and Attribution of Occupational Lung Diseases 176 Other Respiratory Conditions 177 Circulatory Disorders 177 Respiratory Distress Syndrome 179 Air Pollution 180 Carbon Monoxide Poisoning 183 Acidosis 184 Alkalosis and Hyperventilation 184 Hypoxia 186 Altitude Sickness 188 Barotrauma and Decompression Sickness 189 Thoracic Squeeze 192 Drowning 193 Chapter 7: Approaches to Respiratory Evaluation and Treatment 196 Recognizing the Signs and Symptoms of Disease 196 .
Methods of Investigation 199 Pulmonary Function Test 202 Chest X-ray 203 Lung Ventilation/Perfusion Scan 204 Bronchoscopy 205 Mediastinoscopy 208 Types of Respiratory Therapy 210 Drug Therapies 211 Oxygen Therapy 214 Artificial Respiration 218 Thoracentesis 220 Hyperbaric Chamber 221 Lung Transplantation 223 Conclusion 223 202 Glossary 226 Bibliography 228 Index 230 219 .
the most prominent feature of the lung interior are the many small air passages called 11 T . the centre of the respiratory system. eventually reaching the region where gas is exchanged. Here. The larynx is a hollow tube connected to the top of the windpipe. Inside the lungs. But there are many treatments to keep the airways free and clear. or throat. Air that passes through the nose travels to the pharynx. Without this ability. the air is cleansed and moistened before entering the lungs. This structure provides humans with the sense of smell while also filtering. The right lung is slightly larger than the left lung because of the asymmetrical position of the heart. whether by a viral or bacterial infection or through detrimental habits such as smoking. and this air canal to the lungs not only enables humans to speak but also keeps food out of the lower respiratory tract. the cone-shaped passageway leading from the mouth and nose to the larynx. humans could not survive on Earth. warming. It also sheds light on how easily a healthy respiratory system can be damaged. and moistening inhaled air. This book explains the science behind the amazing human respiratory system.7 Introduction 7 he human lungs are amazing feats of nature. there are numerous nerves and blood vessels. They pump vital oxygen through airways and into the bloodstream every second of every day. and the left lung has 8 to 10. or voice box. However. After passing through the larynx. A thin membranous sac known as the pleura covers the lungs. also known as the windpipe. The right lung has 10 airway segments. The anatomy of the human respiratory system starts at the place where air first enters the body—the nose. air travels through the trachea. and this book also describes the many different approaches doctors can take to save patients’ lives and lungs. The clean air then travels into the deep tissues of the lungs.
A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. through the pulmonary veins. is made up of three separate compartments for blood. or respiration. the oxygenated blood is pumped to the rest of the body. The average adult lung has approximately 300 million alveoli. but still keeps them separate.12 inch) to less than 1 mm (less than 0. the pulmonary system. A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 .7 The Respiratory System 7 bronchioles. The second blood system in the lungs. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. The act of breathing. air. controlled by the brain. The bronchial circulation is a vital source of nourishment for the lung tissues. The tissue compartment supports the air and blood compartments and lets them come into close contact. comprises the network of blood vessels supporting the conducting airways themselves. through the pulmonary arteries. the bronchial circulation. is an automatic process. the region where oxygen is transferred to the blood and carbon dioxide is removed. which makes exchanging gases easier. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs. and to the left atrium of the heart. The gas-exchange area. From the heart. which range in diameter from 3 mm (0. Lungs also have two distinct blood circulation systems. which look like cells in a honeycomb. The first of these. thereby delivering oxygen and other nutrients to organs distant from the lungs. and tissue.04 inch). humans and other animals do not need to actively think about breathing in order for it to happen. Thus.
these receptors constrict the airways and cause breathing to become fast and shallow. Some chemoreceptors send signals to the brain when they detect noxious or toxic materials in air as it passes to the lungs. metabolic rate slows and therefore respiration rate decreases and oxygen demand is low. This fine level of regulation is fundamental in maintaining the acid–base balance in the body. others respond to chemical changes in the immediate external environment. Whereas some chemoreceptors respond to changes in oxygen and carbon dioxide levels in the bloodstream. respectively. These effects trigger an increase in respiration rate. The effects of this are illustrated by the differences in respiration rate observed during exercise and during sleep. In the basic mechanics of breathing. During exercise. air moves in and out of the lungs in response to pressure changes. which are located throughout the body. The neural networks controlling breathing receive information from special chemical sensors known as chemoreceptors. 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.7 Introduction 7 abdomen. there also exist sensors that monitor the muscles that control breathing. When stimulated. This response represents the body’s attempt to prevent toxins from entering the lungs. thereby increasing oxygen delivery to tissues and maintaining the body’s acid–base balance. The 13 . during sleep. In addition to the types of sensors described above. metabolic rate and acid levels in muscle tissue increase. One of the major abdominal muscles involved in breathing is the diaphragm. In contrast. which functions to move air in and out of the lungs as it contracts and relaxes.
hiking up during the day and descending down to camp to 14 . The atmospheric pressure of oxygen differs with respect to high versus low altitudes on Earth. This exchange of gases takes place over an immense surface area. which can lead to death. In adults. Oxygen deprivation. At high altitudes. The pulmonary alveoli. transfer carbon dioxide from and add oxygen to blood. the volume of air expired by the lungs can increase by as much as 25 times the normal resting level. Respiration. The amount of air that the lungs pump changes dramatically depending on external or internal conditions. Without oxygen.7 The Respiratory System 7 diaphragm is the major muscle that facilitates breathing. However. The main purpose of respiration is to provide oxygen for the body’s cells. in which the body works to more efficiently utilize oxygen in the air. oxygen is present at lower levels than it is at low altitudes. The lungs serve a fundamental role in ensuring that excess carbon dioxide is removed from the body. an activity that is necessary to supply energy to the cells and the body. and metabolism all work together. The carbon dioxide that is absorbed by the alveoli is expelled from the body during exhalation. circulation. Oxygen is used by cells for the breakdown of nutrients. but it is assisted by a complex assembly of other muscle groups. even for only a few minutes. People who live at high altitudes adapt to this decrease in oxygen availability. the small air spaces in the lungs. The oxygen that the alveoli transfer to the blood is then circulated to the heart and the body’s other tissues. is a gradual process. during vigorous breathing. cells are unable to function properly. acclimatization. Mountain climbers ascending to extreme heights must spend several days at camps established increasingly farther up the mountainside. can cause the brain and the heart to stop functioning.
The common cold is an acute infection of the upper respiratory tract that can sometimes spread to the lower respiratory tissues. as well as bacterial pneumonia. bacteria can cause inflammation of the trachea. as climbers make their way up the mountain. which can lead to high-altitude pulmonary edema. death is caused by drowning. certain viruses and fungi can also cause the disease. Other common upper respiratory conditions include sore throat and pharyngitis. If these precautions are not taken. Before antibiotics were widely available. pneumonia was a widespread and notoriously deadly disease. and in the first decade of the 21st century. which can be particularly dangerous in infants and in the elderly. Essentially. In the lower respiratory system. many people have their tonsils removed after suffering from chronic tonsillitis. Pneumonia also often affects persons with impaired immune systems.7 Introduction 7 sleep at night. in which the body circulates additional blood to the lungs. In the 18th and 19th centuries. Tuberculosis is another example of a respiratory disease caused by bacteria. The 15 . a condition known as tracheitis. This enables the body to adjust to the decreased availability of oxygen. Although bacteria sometimes cause pneumonia. but the blood leaks into the air sacs. it was a leading cause of death. which can arise as a result of infection. For example. Inflammation of respiratory tissues can sometimes be severe and chronic. the emergence of drug-resistant tuberculosis bacteria has resulted in a resurgence of the disease. because these individuals are unable to defend against infectious organisms. the body’s tissues become deprived of oxygen. Various infectious diseases caused by viruses and bacteria can produce difficulties in breathing.
a strain of influenza virus gives rise to a pandemic. snoring is caused by blocked airways. Influenza is a common. no cause has been identified. to form. muscle pains. A respiratory disease of major concern in the world today is lung cancer. For example. One example is idiopathic pulmonary fibrosis. which may be associated with obesity. One of the deadliest influenza pandemics was that of 1918–19. despite extensive research. The term idiopathic means “of unknown cause. Sleep apnea causes affected individuals to awaken periodically through the night. It is a highly contagious disease too. which caused between 25 million and 50 million deaths worldwide. Many respiratory conditions arise from noninfectious causes. or large cheese-like masses. chills. resulting in the formation of cavities in the lungs. One of the best-characterized inherited conditions is cystic fibrosis. This process leads to the eventual breakdown of respiratory tissues. headaches. and stomach pain. in which the collapse of the airways leads to intermittent stoppages in breathing. blood vessels in the lungs burst. sticky mucus that blocks the airways and the digestive tract. seasonal respiratory illness that is caused by viral infection.7 The Respiratory System 7 tuberculosis bacteria spread slowly in the lungs and cause hard nodules (tubercles). and the infected person coughs up bright red blood. which results in progressive shortness of breath until a person can no longer breathe. Eventually. For some diseases of the respiratory system. A severe form of snoring is sleep apnea. an outbreak of the illness that occurs on a global scale and is characterized by rapid spread. the primary symptom of which is the production of a thick. Every few decades.” and thus is used to describe diseases of uncertain origin. Lung cancer can arise as a result of a 16 . Infection is accompanied by fever. Some respiratory diseases are inherited.
most likely resulting from exposure to air pollution. In addition to vaccines and antivirals. although tobacco smoking is the primary cause. or white lung disease. The best-known occupational lung disease is black lung. it was still considered rare. Today. particularly pneumonia and tuberculosis. have been around for years and are readily available. Breathing asbestos can also cause the cancerous condition known as mesothelioma. resulting in an estimated 1. more than 7 percent of children and 9 percent of adults suffer from asthma. however. Several vaccines have been developed to prevent illnesses such as influenza. 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. Now. Breathing problems caused by allergies to environmental conditions are fairly common. Some respiratory diseases arise as a result of occupational. In the early 20th century. or work. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. 17 . Doctors first described the symptoms of lung cancer in the mid-19th century. Construction workers and insulators exposed to asbestos often suffer from asbestosis.3 million fatalities each year. There is hope for those who suffer from respiratory diseases and disorders. lung cancer is the leading cause of cancer deaths worldwide. factors. however. Scientists are constantly researching and developing new and different treatments for respiratory ailments. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. and even cockroaches.7 Introduction 7 variety of factors. Many treatments. which affects coal miners who inhale coal dust for many years. tobacco smoke. Nasal decongestants and antihistamines are examples of commonly used remedies.
the human respiratory system is a finely tuned feat of engineering. chemotherapy. A healthy set of lungs is nothing to take for granted. Treatment may also be based on the results of genetic screening. and radiation. . The best thing a person can do for his or her lungs is to prevent them from becoming diseased in the first place. which can identify mutations that render some lung cancers susceptible to certain drugs. and the consequences of neglecting or damaging that fragile system can be drastic. As this book shows. Sometimes a person’s lung becomes so diseased that the only hope for survival is a lung transplant.7 The Respiratory System 7 Lung cancer treatments may consist of surgery.
or respiration. These actions encompass not only muscular movements but also cellular and chemical processes. Breathing. such as the intrapulmonary bronchi. is fundamental to survival. it is otherwise an automatic process. occurring without our having to think about it. and the alveolar ducts. the trachea. and part of the oral cavity. and though we possess the ability to consciously control the rate of our breathing. The upper airway system comprises the nose and the paranasal cavities (or sinuses). The respiratory system consists of two divisions: upper airways and lower airways. The transition between these two divisions is located where the pathways of the respiratory and digestive systems cross. and all the airways that branch extensively within the lungs. the bronchioles. The lower airway system consists of the larynx.CHAPTER1 ANATOMY AND FUNCTION OF THE HUMAN RESPIRATORY SYSTEM O ur respiratory system provides us with the fundamental ability to breathe: to inhale and exhale air from our lungs. Yet. just at the top of the larynx (or voice box). where its delicate tissues are 19 . supporting this process are a number of complex actions that occur within our bodies. is located in the thorax (or chest). the pharynx (or throat). the stem bronchi. the lung. the design of the respiratory systeM The human gas–exchanging organ. as simple as it is for us to inhale and exhale.
called conducting airways. 20 . Encyclopædia Britannica. carbon dioxide. Atmospheric air is pumped in and out regularly through a system of pipes. The lung provides the body with a continuous flow of oxygen and clears the blood of the gaseous waste product.7 The Respiratory System 7 The lungs serve as the gas-exchanging organ for the process of respiration. protected by the bony and muscular thoracic cage. Inc.
Other elements fundamental to the process of respiration include the blood. sinuses. and pharynx of the upper airways serve the vital role of filtering and warming air as it enters the respiratory tract. under the control of the central nervous system. It is subdivided into a left and right canal by a thin medial cartilaginous and bony wall. the heart and the blood vessels). the collaboration of other organ systems is essential. The oral cavity. the pumping action on the lung. For respiration.7 Anatomy and Function of the Human Respiratory System 7 which connect the gas–exchange region inside the body with the environment outside the body. which pumps blood from the heart to the lungs and the rest of the body. The muscles expand and contract the internal space of the thorax. and the circulatory system (i. Morphology of the upper airways The nose. as the main respiratory muscle. and the intercostal muscles of the chest wall play an essential role by generating. such as enabling the sensation of smell. The filtering process is vital to clearing inhaled air of dust and other debris.. the nasal cavity. whose bony framework is formed by the ribs and the thoracic vertebrae.e. which acts as a carrier of gases. the structures of the upper respiratory tract also have other important functions. is sometimes also considered a part of the upper airways. In addition to fulfilling a fundamental role in respiration. The diaphragm. the nasal 21 . through which air may be inhaled or exhaled. and it protects against the passage into the lungs of potentially infectious foreign agents. The Nose The nose is the external protuberance of an internal space.
from the lateral wall. the mucosa of the nose contains mucus-secreting glands and venous plexuses. and they reach their final size around age 20. This structural design 22 . the ethmoid sinuses. it is also flooding the nasal cavity. The paranasal sinuses are sets of paired single or multiple cavities of variable size. which also forms the roof of the oral cavity. The nasal cavity with its adjacent spaces is lined by a respiratory mucosa. the epithelium. Each canal opens to the face by a nostril and into the pharynx by the choana. the intranasal space communicates with a series of neighbouring air-filled cavities within the skull (the paranasal sinuses) and also. ciliated and secreting cells. The sinuses are located in four different skull bones: the maxilla. The sinuses have two principal functions: because they are filled with air. On each side. which is located in the upper posterior wall of the nasal cavity. they help keep the weight of the skull within reasonable limits. The duct drains the lacrimal fluid into the nasal cavity. the frontal sinus. Typically. Most of their development takes place after birth.7 The Respiratory System 7 septum. which is the largest cavity. ethmoid. middle. Correspondingly. they are called the maxillary sinus. and the sphenoid sinus. middle. The passageways thus formed below each ridge are called the superior. This fact explains why nasal respiration can be rapidly impaired or even impeded during weeping: the lacrimal fluid is not only overflowing into tears. The complex shape of the nasal cavity results from projections of bony ridges. consists principally of two cell types. and inferior nasal meatuses. with the lacrimal apparatus in the corner of the eye. The floor of the nasal cavity is formed by the palate. frontal. and sphenoid bones. and they serve as resonance chambers for the human voice. and inferior turbinate bones (or conchae). the superior. via the nasolacrimal duct. Its top cell layer.
preparing it for intimate contact with the delicate tissues of the gas-exchange area.7 Anatomy and Function of the Human Respiratory System 7 Sagittal view of the human nasal cavity. About two dozen olfactory nerves convey the sensation of smell from the 23 . is lined by skin that bears short thick hairs called vibrissae. Inc. During expiration through the nose. Encyclopædia Britannica. moisten. Two regions of the nasal cavity have a different lining. They clean. reflects the particular ancillary functions of the nose and of the upper airways in general with respect to respiration. The vestibule. a process that saves water and energy. at the entrance of the nose. and warm the inspired air. the air is dried and cooled. In the roof of the nose. the olfactory organ with its sensory epithelium checks the quality of the inspired air.
Inc. 24 . The Pharynx For the anatomical description. In the posterior wall of the Sagittal section of the pharynx. the nasopharynx. The upper floor. It is also connected to the tympanic cavity of the middle ear through the auditory tubes that open on both lateral walls. is primarily a passageway for air and secretions from the nose to the oral pharynx.7 The Respiratory System 7 olfactory cells through the bony roof of the nasal cavity to the central nervous system. 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. Encyclopædia Britannica. the pharynx can be divided into three floors.
it may interfere with nasal respiration and alter the resonance pattern of the voice. a cartilaginous. trachea. Lying directly above the larynx. the diaphragm. and the sternum (or breastbone) and is separated from the abdominal cavity (the body’s largest hollow space) by a muscular and membranous partition. 25 . it represents the site where the pathways of air and food cross each other: air from the nasal cavity flows into the larynx. which is the second–largest hollow space of the body.7 Anatomy and Function of the Human Respiratory System 7 nasopharynx is located a lymphatic organ. The lungs reside within the thoracic cavity (chest cavity). When it is enlarged (as in tonsil hypertrophy). Also residing within the thoracic cavity is the tracheobronchial tree: the heart. which roofs the posterior part of the oral 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. It is delimited from the nasopharynx by the soft palate. leafshaped flap. The lower floor of the pharynx is called the hypopharynx. Its anterior wall is formed by the posterior part of the tongue. and lungs. The middle floor of the pharynx connects anteriorly to the mouth and is therefore called the oral pharynx or oropharynx. functions as a lid to the larynx and. The cavity is enclosed by the ribs. the vessels transporting blood between the heart and the lungs. the pharyngeal tonsil. while the lungs themselves receive the air and facilitate the process of gas exchange. the vertebral column. during the act of swallowing. controls the traffic of air and food. The first two of these provide a canal for the passage of air to the lungs. The epiglottis. Morphology of the lower airways The major structures of the lower airways include the larynx.
is made of two plates fused 26 . or serum. between the parietal and the visceral pleura. the two surfaces tend to touch. The largest cartilage of the larynx. the heart. as the mediastinal pleura. interconnected by ligaments and membranes. the thyroid cartilage. the muscles must be anchored to a stabilizing framework. and as the organ of phonation. For the precise function of the muscular apparatus. The chest cavity is lined with a serous membrane. where it is called the visceral pleura. most of them minute. when it occurs. and the great vessels. Sound is produced by forcing air through a sagittal slit formed by the vocal cords. the glottis. The Larynx The larynx is an organ of complex structure that serves a dual function: as an air canal to the lungs and a controller of its access. This causes not only the vocal cords but also the column of air above them to vibrate. so called because it exudes a thin fluid. The laryngeal skeleton consists of almost a dozen pieces of cartilage. and over part of the esophagus. The pleural cavity is the space. this function can be closely controlled and finely tuned. As evidenced by trained singers. Because the atmospheric pressure between the parietal pleura and the visceral pleura is less than that of the outer atmosphere. Control is achieved by a number of muscles innervated by the laryngeal nerves. friction between the two during the respiratory movements of the lung being eliminated by the lubricating actions of the serous fluid. This portion of the chest membrane is called the parietal pleura. the mediastinum being the space and the tissues and structures between the two lungs.7 The Respiratory System 7 and the major veins into which the blood is collected for transport back to the heart. The membrane continues over the lung.
Both of these structures are easily felt through the skin. the arytenoid cartilages. Behind the shieldlike thyroid cartilage. resembling an organ pipe. The cricoid is located below the thyroid cartilage. 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. made of elastic tissue. they are also formed by the free end 27 . to which it is joined in an articulation reinforced by ligaments. Because the arytenoid cartilages rest upright on the cricoid plate. has a signet-ring shape. 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.7 Anatomy and Function of the Human Respiratory System 7 anteriorly in the midline. the laryngeal prominence. The vocal ligaments are part of a tube. Viewed frontally. The angle between the two cartilage plates is sharper and the prominence more marked in men than in women. This mechanism plays an important role in altering length and tension of the vocal cords. The broad plate of the ring lies in the posterior wall of the larynx and the narrow arch in the anterior wall. they follow its tilting movement. The transverse axis of the joint allows a hingelike rotation between the two cartilages. Just above the vocal cords there is an additional pair of mucosal folds called the false vocal cords or the vestibular folds. the thyroid notch. This movement tilts the cricoid plate with respect to the shield of the thyroid cartilage and hence alters the distance between them. with its narrowest width at the glottis. Like the true vocal cords. which has given this structure the common name of Adam’s apple. the vocal cords span the laryngeal lumen. another large cartilaginous piece of the laryngeal skeleton. The arytenoid cartilages articulate with the cricoid plate and hence are able to rotate and slide to close and open the glottis. Just above the vocal cords. below it is a forward projection. At the upper end of the fusion line is an incision.
during high-pitched phonation or swallowing) or downward. The extrinsic muscles join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. This space is called the ventricle of the larynx. The mucosal layer contains mucous glands. the latter can easily be seen from above with the laryngoscope. The muscular apparatus of the larynx comprises two functionally distinct groups. The right main bronchus has a larger diameter. is oriented more vertically. length. The extrinsic muscles act on the larynx as a whole. an instrument designed for visual inspection of the interior of the larynx. and tension of the vocal cords. The interior of the trachea is lined by the typical respiratory epithelium.7 The Respiratory System 7 of a fibroelastic membrane. The intrinsic muscles attach to the skeletal components of the larynx itself. At its lower end. moving it upward (e. Its wall is stiffened by 16 to 20 characteristic horseshoe-shaped. the trachea divides in an inverted Y into the two stem (or main) bronchi. a tube about 10 to 12 cm (4 to 5 inches) long and 2 cm (0. Between the vestibular folds and the vocal cords.. one each for the left and right lung.g. and is shorter than the left main bronchus. The practical consequence of 28 .8 inch) wide. 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 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. incomplete cartilage rings that open toward the back and are embedded in a dense connective tissue. the laryngeal space enlarges and forms lateral pockets extending upward.
structural design of the airway tree The hierarchy of the dividing airways. and partly also of the blood vessels penetrating the lung. largely determines the internal lung structure. In modeling the human airway tree. purely gas-exchanging zone. The models calculate the average path from the trachea to the lung periphery as consisting of about 24 to 25 generations of branches. From a morphological point of view. however. however. may range from 11 to 30 generations. however. it makes sense to distinguish the relatively thick-walled.7 Anatomy and Function of the Human Respiratory System 7 this arrangement is that foreign bodies passing beyond the larynx will usually slip into the right lung. The structure of the stem bronchi closely matches that of the trachea. purely airconducting tubes from those branches of the airway tree structurally designed to permit gas exchange. The structural design of the airway tree is functionally important because the branching pattern plays a role in determining air flow and particle deposition. the daughter branches may differ greatly in length and diameter. and a transitional zone in between. Regular dichotomy means that each branch of a treelike structure gives rise to two daughter branches of identical dimensions. where both functions grade into one another. Functionally. Individual paths. The transition between the conductive and the respiratory portions of an airway lies on average at the end of the 16th generation. if the trachea is counted as generation zero. purely conducting zone. 29 . In irregular dichotomy. a peripheral. the intrapulmonary airway system can be subdivided into three zones: a proximal. it is generally agreed that the airways branch according to the rules of irregular dichotomy.
this fluid layer is topped by a blanket of mucus of high viscosity. the two stem bronchi. This design can be compared to a conveyor belt for particles. and clean the inspired air and distribute it to the gas-exchanging zone of the lung. their height decreasing with the narrowing of the tubes. the airway structure is greatly altered by the appearance of cuplike outpouchings from the walls. These form minute air chambers and represent the first gas-exchanging alveoli on the airway path. In bronchioles the goblet cells are completely replaced by another type of secretory cells named Clara cells. the walls of the bronchioles. devoid of cartilage. where they are swallowed. the bronchi. In the alveoli. In larger airways. Ciliated cells are present far down in the airway tree. Their function is to further warm. They are lined by the typical respiratory epithelium with ciliated cells and numerous interspersed mucus-secreting goblet cells. the respiratory epithelium gives way to a particularly flat lining layer that permits the formation of a thin air–blood barrier. gain their stability from their structural integration into the gas-exchanging tissues.7 The Respiratory System 7 The conducting airways comprise the trachea. Whereas cartilage rings or plates provide support for the walls of the trachea and bronchi. rhythmic beat directed outward. as does the frequency of goblet cells. moisten. and indeed the mechanism is referred to as the mucociliary escalator. The epithelium is covered by a layer of low-viscosity fluid. Distally. within which the cilia exert a synchronized. The last purely conductive airway generations in the lung are the terminal bronchioles. the alveoli are so densely packed along the airway that an airway wall 30 . After several generations of such respiratory bronchioles. The mucus layer is dragged along by the ciliary action and carries the intercepted particles toward the pharynx. and the bronchioles.
a right and a left. The final generations of the airway tree end blindly in the alveolar sacs. separated from each other by a deep horizontal and an oblique fissure. while their apexes extend above the first rib. a circumscribed area where airways. and inferior lobe. The space between them is filled by the mediastinum. smaller in volume because of the asymmetrical position of the heart. the two lungs rest with their bases on the diaphragm. Gross Anatomy Together. blood and lymphatic vessels. middle. Medially. the lungs Humans have two lung organs. In the thorax.7 Anatomy and Function of the Human Respiratory System 7 proper is missing. the trachea with the stem bronchi. and each is connected with the trachea by its main bronchus (large air passageway) and with the heart by the pulmonary arteries. a superior. which are located in the chest cavity and are responsible for adding oxygen to and removing carbon dioxide from the blood. In humans each lung is encased in a thin membranous sac called the pleura. major blood vessels. the lungs occupy most of the intrathoracic space. and the thymus gland. The left lung. they are connected with the mediastinum at the hilum. the esophagus. and the airway consists of alveolar ducts. which corresponds to a connective tissue space containing the heart. and nerves enter or leave the lungs. The right lung represents 56 percent of the total lung volume and is composed of three lobes. The right and left lungs are slightly unequal in size. The parietal pleura and the visceral pleura that line the inside 31 . has only two lobes separated by an oblique fissure.
are in direct continuity at the hilum. the recesses are partly opened by the expanding lung. the lungs are maintained in close apposition to the thoracic wall by a negative pressure between visceral and parietal pleurae. Inc. so the pleural cavity is larger than the lung volume.7 The Respiratory System 7 Anatomy of the human lungs. costal. the parietal pleura can be subdivided into three portions: mediastinal. of the thoracic cavities and the lung surface. A thin film of extracellular fluid between the pleurae enables 32 . respectively. Encyclopædia Britannica. The presence of pleural recesses form a kind of reserve space. thus allowing the lung to increase in volume. and diaphragmatic pleurae. Depending on the subjacent structures. Although the hilum is the only place where the lungs are secured to surrounding structures. During inspiration.
Furthermore. the cartilage rings of the stem bronchi are replaced by irregular cartilage plates. This outer fibrous layer contains. The Bronchi and Bronchioles In the intrapulmonary bronchi. besides lymphatics and nerves. a layer of smooth muscle is added between the mucosa and the fibrocartilaginous tunic. depending on the classification. If air enters a pleural cavity (pneumothorax). the pulmonary segments. respiratory movements can be painful. Unlike the lobes. the lung immediately collapses owing to its inherent elastic properties. and breathing is abolished on this side. the arterial supply follows the segmental bronchi. These anatomical features are important because pathological processes may be limited to discrete units. If the serous membranes become inflamed (pleurisy).7 Anatomy and Function of the Human Respiratory System 7 the lungs to move smoothly along the walls of the cavity during breathing. There are 10 segments in the right lung and 8 to 10 segments in the left lung. and the surgeon can remove single diseased segments instead of whole lobes. the pulmonary segments are not delimited from each other by fissures but by thin membranes of connective tissue containing veins and lymphatics. Pulmonary Segments The lung lobes are subdivided into smaller units. 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. small bronchial vessels to supply the bronchial wall with blood from the systemic circulation. Bronchioles are 33 .
and vice versa. through the 160 square metres (about 1. while the supplying structures. Their lumen is lined by a simple cuboidal epithelium with ciliated cells and Clara cells. an adult human lung has about 300 million alveoli. capable of narrowing the airway. The respiratory gases diffuse from air to blood. and tissue. The airways are then called alveolar ducts and. and it allows them to come into close contact with each other (thereby facilitating gas exchange) while keeping them strictly confined. until after two to four generations of respiratory bronchioles. Distally. Whereas air and blood are continuously replenished. Abnormal spasms of this musculature cause the clinical symptoms of bronchial asthma. The gas-exchange region begins with the alveoli of the first generation of respiratory bronchioles. the frequency of alveolar outpocketings increases rapidly.7 The Respiratory System 7 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. The Gas-Exchange Region The gas-exchange region comprises three compartments: air. the function of the tissue compartment is twofold: it provides the stable supporting framework for the air and blood compartments. and non-capillary blood vessels belong to the non-parenchyma. conductive airways. The bronchiolar wall also contains a well-developed layer of smooth muscle cells. They are polyhedral structures. in the last generation. lymphatics. the whole wall is formed by alveoli. blood. alveolar sacs. The walls of the bronchioles lack cartilage and seromucous glands. On average.722 square feet) of internal surface area of the tissue compartment. with a 34 .
and their cell bodies abound in granules of various content. called the interalveolar septum. Before it is released into the airspaces. On top of the epithelium. Ultimately. covers between 92 and 95 percent of the gas-exchange surface. and their task is to keep the air–blood barrier clean and unobstructed. and open on one side. where they connect to the airway. Type II pneumocytes produce a surface-tension-reducing material. or cell debris originating from cell damage or normal cell death. The alveolar wall. The fibre system is interwoven with the capillaries and particularly reinforced at the alveolar entrance rings. the pulmonary surfactant. the thin air–blood barrier for gas exchange. It contains connective tissue and interstitial 35 . more cuboidal cell type. the type II pneumocyte. the type I pneumocyte. The capillaries are lined by flat endothelial cells with thin cytoplasmic extensions. The interalveolar septum is covered on both sides by the alveolar epithelial cells. whereas type II cells are secretory. The tissue space between the endothelium of the capillaries and the epithelial lining is occupied by the interstitium. the smallest of the blood vessels. which spreads on the alveolar surface and prevents the tiny alveolar spaces from collapsing. partly foreign material that may have reached the alveoli. squamous cell type. is common to two adjacent alveoli. The type I cells form. a second. covers the remaining surface. the alveolar macrophages are derived from the bone marrow. It contains a dense network of capillaries.7 Anatomy and Function of the Human Respiratory System 7 diameter of about 250 to 300 micrometres. and a skeleton of connective tissue fibres. pulmonary surfactant is stored in the type II cells in the form of lamellar bodies. These granules are the conspicuous ultrastructural features of this cell type. A thin. together with the endothelial cells. alveolar macrophages creep around within the surfactant fluid. They are large cells.
Blood. to prevent the accumulation of extracellular fluid in the interalveolar septa. which seem to be endowed with contractile properties. If for some reason the delicate fluid balance of the pulmonary tissues is impaired. As a consequence. following relatively closely the course of the dividing airway tree.7 The Respiratory System 7 fluid. amorphous ground substance. low in oxygen content but laden with carbon dioxide. and Nerves With respect to blood circulation. The connective tissue comprises a system of fibres. The oxygenated blood from the capillaries is collected by 36 . After numerous divisions. alternatively. Lymphatic Vessels. the pulmonary arteries. the respiratory gases must diffuse across longer distances. and proper functioning of the lung is severely jeopardized. Because intravascular pressure determines the arterial wall structure. which have on average a pressure five times lower than systemic arteries. The pulmonary (or lesser) circulation is responsible for the oxygen supply of the organism. Blood Vessels. small arteries accompany the alveolar ducts and split up into the alveolar capillary networks. This pathological condition is called pulmonary edema. The fibroblasts are thought to control capillary blood flow or. is carried from the right heart through the pulmonary arteries to the lungs. It has two distinct but not completely separate vascular systems: a low-pressure pulmonary system and a high-pressure bronchial system. the lung is a complex organ. are much flimsier than systemic arteries of corresponding size. the pulmonary artery enters the lung in the company of the stem bronchus and then divides rapidly. and cells (mainly fibroblasts). On each side. an excess of fluid accumulates in the lung tissue and within the airspaces.
called bronchomediastinal trunks. Small bronchial veins exist. The interlobular veins then converge on the intersegmental septa. They split up into capillaries surrounding the walls of bronchi and vessels and also supply adjacent airspaces. The superficial. four pulmonary veins drain blood from the lung and deliver it to the left atrium of the heart.7 Anatomy and Function of the Human Respiratory System 7 venules and drained into small veins. These do not accompany the airways and arteries but run separately in narrow strips of connective tissue delimiting small lobules. Most of their blood is naturally collected by pulmonary veins. originating from the peribronchial venous plexuses and draining the blood through the hilum into the azygos and hemiazygos veins of the posterior thoracic wall. Finally. The lymph is drained from the lung through two distinct but interconnected sets of lymphatic vessels. The bronchial arteries originate from the aorta or from an intercostal artery. lymph nodes exert their filtering action on the lymph before it is returned into the blood through the major lymphatic vessels. The bronchial circulation has a nutritional function for the walls of the larger airways and pulmonary vessels. subpleural lymphatic network collects the lymph from the peripheral mantle of lung tissue and drains it partly along the veins toward the hilum. they end several generations short of the terminal bronchioles. near the hilum the veins merge into large venous vessels that follow the course of the bronchi. Lymph drainage 37 . however. Within the lung and the mediastinum. The deep lymphatic system originates around the conductive airways and arteries and converges into vessels that mostly follow the bronchi and arterial vessels into the mediastinum. With a few exceptions. They are small vessels and generally do not reach as far into the periphery as the conducting airways. Generally.
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
Although the diaphragm is the major muscle of breathing. 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. Chemoreceptors detect changes in blood oxygen levels and change the acidity of the blood and brain. its respiratory action is assisted and augmented by a complex assembly of other muscle groups. the force of respiratory muscle contraction. 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. chewing and swallowing.7 The Respiratory System 7 swings in carbon dioxide production and oxygen consumption caused by changes in metabolic rate. they also complicate the regulation of breathing. abdominal muscles. Mechanoreceptors monitor the expansion of the lung. and maintaining posture. These same muscles are used to perform a number of other functions. Perhaps because the “respiratory” muscles are employed in performing nonrespiratory functions. In addition. This flexibility in breathing patterns in large part arises from sensors distributed throughout the body that send signals to the respiratory neuronal networks in the brain. breathing can be 42 . Intercostal muscles inserting on the ribs. and the extent of muscle shortening. such as the airway narrowing that occurs in an asthmatic attack. such as speaking. The respiratory system is also able to compensate for disturbances that affect the mechanics of breathing. the size of the airway. 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.
Shutterstock.com 43 .7 Control and Mechanics of Breathing 7 Singing demands a strong diaphragm to control breath.
a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree. in turn they drive cranial motor neurons. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . Neurally. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. Input into the respiratory control system from higher brain centres may help optimize breathing so that not only are metabolic demands satisfied by breathing but ventilation also is accomplished with minimal use of energy. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. 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. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. allowing the activity of these physiological systems to be coordinated with respiration. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla.
expiratory neurons discharge and inspiratory neurons are strongly inhibited. There may be no peripheral manifestation of expiratory neuron discharge except for the absence of inspiratory muscle activity. breathing is characterized by prolonged inspiratory activity that may last for several minutes. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. When the vagus nerves are sectioned or pontine centres are destroyed. offswitch. is called apneustic breathing. This type of breathing. 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. but at a much lower level. which occasionally occurs in persons with diseases of the brain stem. Offswitch neurons in the medulla terminate inspiration. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. After a gap of a few milliseconds. inspiratory activity is restarted. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. As the activity of the post-inspiratory neurons subsides. post-inspiratory. This increase in activity. early inspiratory.7 Control and Mechanics of Breathing 7 abruptly. Mechanically. although in upright humans the lower expiratory intercostal muscles 45 . Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. and gradually declines until the onset of expiratory neuron activity. which produces lung expansion. Then the cycle begins again. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. and expiratory.
There are two kinds of respiratory chemoreceptors: arterial chemoreceptors. lowering carbon dioxide levels three to four millimetres of mercury below values occurring during wakefulness can cause a total cessation of breathing (apnea). with exercise). Ventilation levels behave as if they were regulated to maintain a constant level of carbon dioxide partial pressure and to ensure adequate oxygen levels in the arterial blood. During sleep and anesthesia. which respond to changes in the partial pressure of carbon dioxide in their immediate environment. Moreover. Peripheral Chemoreceptors Hypoxia. as the demand to breathe increases (for example. which leads to a reduction in chemoreceptor activity and a diminution of ventilation. As expiration proceeds. Conversely. too much ventilation depresses the partial pressure of carbon dioxide.7 The Respiratory System 7 and the abdominal muscles may be active even during quiet breathing. and central chemoreceptors in the brain. the inhibition of the inspiratory muscles gradually diminishes and inspiratory neurons resume their activity. cheMoreceptors One way in which breathing is controlled is through feedback by chemoreceptors. which monitor and respond to changes in the partial pressure of oxygen and carbon dioxide in the arterial blood. more expiratory intercostal and abdominal muscles contract. by a 46 . or the reduction of oxygen supply to tissues to less than physiological levels (produced. for example. Increased activity of chemoreceptors caused by hypoxia or an increase in the partial pressure of carbon dioxide augments both the rate and depth of breathing. which restores partial pressures of oxygen and carbon dioxide to their usual levels.
The type I cells are arranged in groups and are surrounded by type II cells. the carotid body increases its activity linearly as the partial pressure of carbon dioxide in arterial blood is raised. the principal arterial chemoreceptors. vasoactive 47 . as reflected in the size of carotid body signals. contain electron-dense vesicles. Fine sensory nerve fibres are found in juxtaposition to type I cells. Larger oscillations in the partial pressure of carbon dioxide occur with breathing as metabolic rate is increased. The type II cells are generally not believed to have a direct role in chemoreception. which. In addition to responding to hypoxia. a branch of the glossopharyngeal nerve. stimulates the carotid and aortic bodies. The carotid body communicates with medullary respiratory neurons through sensory fibres that travel with the carotid sinus nerve. and neuropeptides such as enkephalins. The two carotid bodies are small organs located in the neck at the bifurcation of each of the two common carotid arteries into the internal and external carotid arteries. may be used by the brain to detect changes in the metabolic rate and to produce appropriate adjustment in ventilation. 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). unlike type II cells. Microscopically. responding more to rapid than to slow changes in the partial pressure of carbon dioxide. The sensory nerve from the carotid body increases its firing rate hyperbolically as the partial pressure of oxygen falls. catecholamines. The amplitude of these fluctuations. the carotid body consists of two different types of cells.7 Control and Mechanics of Breathing 7 trip to high altitudes). Acetylcholine. and the carotid body senses these fluctuations. This arterial blood parameter rises and falls as air enters and leaves the lungs.
which suggests that the same mechanisms are not used to sense or transmit changes in oxygen or carbon dioxide. inhaling gases that contain carbon dioxide stimulates breathing. which then act on the sensory nerve. Carbon dioxide increases the acidity of the fluid surrounding the cells but also easily passes into cells and thus can make the interior of cells more acidic. It is not clear whether the receptors respond to the intracellular or extracellular effects of carbon dioxide or acidity.7 The Respiratory System 7 intestinal peptide. ventilation increases nearly linearly. Even if both the carotid and aortic bodies are removed. It is believed that hypoxia and hypercapnia (excessive carbon dioxide in the blood) cause the release of one or more of these neuroactive substances from the type I cells. It is possible to interfere independently with the responses of the carotid body to carbon dioxide and oxygen. The aortic bodies located near the arch of the aorta also respond to acute changes in the partial pressure of oxygen. Ventilation normally increases by two to four litres per minute with each one millimetre of mercury increase in the partial pressure of carbon dioxide. As the partial pressure of carbon dioxide in arterial blood rises. and substance P. are located within the vesicles. Central Chemoreceptors Carbon dioxide is one of the most powerful stimulants of breathing. The aortic bodies are responsible for many of the cardiovascular effects of hypoxia. Current thinking places these receptors near the undersurface (ventral part) of the 48 . but less well than the carotid body responds to changes in the partial pressure of carbon dioxide. This observation shows that there must be additional receptors that respond to changes in the partial pressure of carbon dioxide.
Inflation of the lungs in animals stops breathing by a reflex described by German physiologist Ewald Hering and Austrian physiologist Josef Breuer. Too much force stimulates tendon organs and causes decreasing motor discharge to the respiratory muscles and may prevent the muscles from damaging themselves. monitor changes in the force produced by muscle contraction. Stimulation of these receptors. The same areas of the ventral medulla also contain vasomotor neurons that are concerned with the regulation of blood pressure. Muscle and Lung Receptors Receptors in the respiratory muscles and in the lung can also affect breathing patterns. Generally. Changes in the length of a muscle affect the force it can produce when stimulated.7 Control and Mechanics of Breathing 7 medulla. These receptors are particularly important when lung function is impaired. Tendon organs. 49 . They believe that respiratory chemoreceptors that respond to carbon dioxide are more diffusely distributed in the brain. 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. because they can help maintain tidal volume and ventilation at normal levels. called spindles. 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. another receptor in muscles. which excites stretch receptors in the airways. The Hering-Breuer reflex is initiated by lung expansion. Receptors. there is a length at which the force generated is maximal.
shortens inspiratory times as tidal volume (the volume of air inspired) increases. by the vagus nerve. Some of these receptors (called irritant receptors) are innervated by myelinated nerve fibres. may be to defend the lung against noxious material in the atmosphere. When stimulated. These receptors are supplied. and thus breathing generally becomes deeper and the number of breaths taken per minute increases. increased levels of oxygen are needed to fuel muscle function. and prostaglandins. bradykinin. 50 . the body’s metabolic rate slows. Variations in breathing Variations in breathing result from changes in metabolic demands in the tissues of the body.7 The Respiratory System 7 which send signals to the medulla by the vagus nerve. during exercise. At the opposite end of the spectrum. When lung inflation is prevented. these receptors constrict the airways and cause rapid shallow breathing. others (the J receptors) by unmyelinated fibres. which inhibits the penetration of injurious agents into the bronchial tree. Stimulation of irritant receptors also causes coughing. This in turn leads to fluctuations in breathing patterns. However. however. 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. like the stretch receptors. There are also receptors in the airways and in the alveoli that are excited by rapid lung inflations and by chemicals such as histamine. the reflex allows inspiratory time to be lengthened. The most important function of these receptors. during sleep. helping to preserve tidal volume. For example. and thus breathing typically becomes lighter. accelerating the frequency of breathing.
thus preserving acid–base homeostasis. which can sense breath-bybreath oscillations in the partial pressure of carbon dioxide. arterial chemoreceptors. the arterial chemoreceptors. and thermal receptors all work in concert during exercise to enhance ventilation. and thermal receptors. Mechanoreceptors. Sources of these signals include mechanoreceptors in the exercising limbs.7 Control and Mechanics of Breathing 7 Exercise One of the remarkable features of the respiratory control system is that ventilation increases sufficiently to keep the partial pressure of carbon dioxide in arterial blood nearly unchanged despite the large increases in metabolic rate that can occur with exercise. A number of signals arise during exercise that can augment ventilation. Shutterstock.com 51 . because body temperature rises as metabolism increases.
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. 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. after the physicians who first described it. how these various mechanisms are adjusted to maintain acid–base balance. with intermittent periods of apnea. The effects on ventilatory pattern vary with sleep stage. because parallel increases occur in the output from the motor cortex to the exercising limbs and to respiratory neurons. This rhythmic waxing and waning of breathing. or even apnea (cessation of breathing). Sufficiently large decreases in the partial pressure of oxygen or increases in the partial pressure of carbon dioxide will cause arousal and terminate sleep. body metabolism is reduced. In slow-wave sleep.7 The Respiratory System 7 The brain also seems to anticipate changes in the metabolic rate caused by exercise. 52 . breathing can become quite erratic. The mechanism that produces the Cheyne-Stokes ventilation pattern is still argued. but it may entail unstable feedback regulation of breathing. is called Cheyne-Stokes breathing. During sleep. It remains unclear. breathing is diminished but remains regular. Similar swings in ventilation sometimes occur in persons with heart failure or with central nervous system disease. however. whereas in rapid eye movement sleep. ventilation may swing between periods when the amplitude and frequency of breathing are high and periods in which there is little attempt to breathe. Sleep During sleep. Ventilatory responses to inhaled carbon dioxide and to hypoxia are less in all sleep stages than during wakefulness.
ventilation during sleep may intermittently fall to low levels or cease entirely because of partial or complete blockage of the upper airways.7 Control and Mechanics of Breathing 7 In addition. in males. have normal upper airway anatomy. Because arousal is often associated with the termination of episodes of obstruction. portions of the larynx and pharynx may be narrowed by fat deposits or by enlarged tonsils and adenoids. In some persons with sleep apnea syndrome. flow is determined by how 53 . however. sleep is of poor quality. which increase the likelihood of obstruction. undergo phasic changes in their electrical activity synchronous with respiration. air is blown from the lungs (expiration). Because atmospheric pressure remains relatively constant. Many of the upper airway muscles. The condition. Others. Snoring and disturbed behaviour during sleep may also occur. like the tongue and laryngeal adductors. termed sleep apnea syndrome. The flow of air is rapid or slow in proportion to the magnitude of the pressure difference. and in the obese. and complaints of excessive daytime drowsiness are common. and obstruction may occur because of discoordinated activity of upper airway and chest wall muscles. air enters the lungs (inspiration). and the reduced activity of these muscles during sleep may lead to upper airway closure. the Mechanics of breathing Air moves in and out of the lungs in response to differences in pressure. leading to severe drops in the levels of blood oxygenation. provided the larynx is open. When the air pressure within the alveoli exceeds atmospheric pressure. When the air pressure within the alveolar spaces falls below atmospheric pressure. this intermittent obstruction occurs repeatedly during the night. occurs most commonly in the elderly. In some individuals. in the newborn.
7 The Respiratory System 7 The diaphragm contracts and relaxes. There is. much above or below atmospheric pressure the pressure within the lungs rises or falls. A difference in air pressure between atmosphere and lungs is created. When the muscles of inspiration relax. Each small increment of expansion transiently increases the space enclosing lung air. Alveolar pressure fluctuations are caused by expansion and contraction of the lungs resulting from tensing and relaxing of the muscles of the chest and abdomen. forcing air in and out of the lungs. Inc. and air flows in until equilibrium with atmospheric pressure is restored at a higher lung volume. therefore. the volume of chest and lungs 54 . less air per unit of volume in the lungs and pressure falls. Encyclopædia Britannica.
tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. This negative (below-atmospheric) pressure is a measure. lung air becomes transiently compressed. 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. A lung is similar to a balloon in that it resists stretch. then. This. therefore. 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 pleural pressure reflects primarily two forces: 55 . resulting in flow of air into or out of the lung and establishment of a new lung volume. its pressure rises above atmospheric pressure. In summary. 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 7 decreases. 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. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. This tendency of the lung to collapse or pull away from the chest is measurable by carefully placing a blunt needle between the outside of the lung and the inside of the chest wall. thereby allowing the lung to separate from the chest at this particular spot. of the force required to keep the lung distended.
The force required to maintain inflation of the lung and to cause airflow is provided by the chest and diaphragm. the force required to cause airflow in and out of the lung. When these muscles relax.7 The Respiratory System 7 1. This additional muscular force is removed on relaxation 56 . air is sucked into the chest and the lung collapses (pneumothorax) when the chest wall is perforated. these would collapse. The lung– chest system thus acts as two opposed coiled springs. Were it not for the outward traction of the chest on the lungs. as by a wound or by a surgical incision. muscle contraction is added to the outward elastic force of the chest to increase the traction on the lung required for its additional stretch. the length of each of which is affected by the other. the chest would expand to a larger size and the diaphragm would fall from its dome-shaped position within the chest. the force required to keep the lung inflated against its elastic recoil and 2. 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. Because the pleural pressure is below atmospheric pressure. During inspiration. Contraction of the abdominal muscles displaces the equilibrium in the opposite direction by adding increased abdominal pressure to the retraction of lungs. which are in turn stretched inward by the pull of the lungs. the additional retraction of lung returns the system to its equilibrium position. And were it not for the inward traction of the lungs on the chest and diaphragm. thereby further raising the diaphragm and causing forceful expiration.
such as pieces of glass. The volume in these circumstances is known as the residual volume. muscular contraction occurs only on inspiration. from a normal resting level of about six litres (366 cubic inches) per minute to 150 litres (9. At total relaxation of the muscles of inspiration and expiration.7 Control and Mechanics of Breathing 7 and the original lung volume is restored. Further reduction of the lung volume results from maximal contraction of the expiratory muscles of chest and abdomen. Additional collapse of the lung to its “minimal air” can be accomplished only by opening the chest wall and creating a pneumothorax. The membranes of the surface of the lung (visceral pleura) and on the inside of the chest (parietal pleura) are normally kept in close proximity (despite the pull of lung and chest in opposite directions) by surface tension of the thin layer of fluid covering these surfaces. the lung is distended to a volume—called the functional residual capacity—of about 40 percent of its maximum volume at the end of full inspiration. capable of increasing its output 25 times. it is about 20 percent of the volume at the end of full inspiration (known as the total lung capacity). The Respiratory Pump and Its Performance The energy expended on breathing is used primarily in stretching the lung– chest system and thus causing airflow. separated by a film of water. During ordinary breathing. The strength of this bond can be appreciated by the attempt to pull apart two smooth surfaces. expiration being accomplished “passively” by elastic recoil of the lung. It normally amounts to 1 percent of the basal energy requirements of the body but rises substantially during exercise or illness. Pressures 57 .154 cubic inches) per minute in adults. The respiratory pump is versatile.
© www . Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver. The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles.istockphoto.7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1.e. with no space between the vocal cords). can be raised voluntarily to 400 litres per minute. Airflow velocity. 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. The beating of cilia (hairline projections) from cells lining the airways 58 ..
5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. and seven litres.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. Normal lungs. In fact. respectively. totaling about 0. such adherence occasionally does occur and is one of the dreaded complications of premature births. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. 500 millilitres. If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. 59 . 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. cough resulting only when this action cannot keep pace with the rate at which secretions are produced. however. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces.
which is needed to support the functions of the body’s various tissues. it must first undergo a process of gas exchange that occurs at the level of the alveoli in the lungs. The oxygen is then distributed by the blood to the tissues. Gas exchange across the membranous barrier between the alveoli and capillaries is enhanced by the thin nature of the membrane.722 square feet).5 micrometre. in exchange. gas exchange Respiratory gases—oxygen and carbon dioxide—move between the air and the blood across the respiratory exchange surfaces in the lungs. This process of adaptation is necessary to maintain normal physiological function. whereas the carbon dioxide is expelled from the alveoli during exhalation. 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. about 0. The area of the alveolar surface in the adult human is about 160 square metres (1. or ¹/¹00 of the diameter of a human hair. Blood vessels that pass alongside the alveoli membranes absorb the oxygen and. the respiratory system.CHAPTER3 GAS EXCHANGE AND RESPIRATORY ADAPTATION I nhaled air is rich in oxygen. At high altitudes or during activities such as deep-sea diving. transfer carbon dioxide to the alveoli. adapt to variations in atmospheric pressure. however. as well as other organ systems. For inhaled oxygen to reach these tissues. 60 .
Shutterstock.7 Gas Exchange and Respiratory Adaptation 7 Changes in the atmosphere’s pressure occur when deep-sea diving and require the respiratory system to adapt.com 61 .
Convection. Local flows can be increased selectively. The partial pressure of carbon dioxide in this pathway is lower than the partial pressure of oxygen. 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. In a mixture of gases. caused by differing modes of transport in the blood. is responsible for movement of air from the environment into the lungs and for movement of blood between the lungs and the tissues.7 The Respiratory System 7 Respiratory gases move between the environment and the respiring tissues by two principal mechanisms. the partial pressure of each gas is directly proportional to its concentration. The process of diffusion is driven by the difference in partial pressures of a gas between two locales. which in turn is responsive to overall body requirements. Oxygen and carbon dioxide are transported between tissue cells and the lungs by the blood. Respiratory gases also move by diffusion across tissue barriers such as membranes. convection and diffusion. 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. for example. or mass flow. There are large changes in the partial pressures of oxygen and carbon dioxide as these gases move between air and the respiring tissues. in the flow through skeletal muscles during exercise. A gas will diffuse from an area of greater partial pressure to an area of lower partial pressure regardless of the distribution of the partial pressures of other gases. but almost equal quantities of the two gases are involved in metabolism and gas exchange. as occurs. The quantity transported is determined both by the rapidity with which the blood circulates and the concentrations of gases in blood. The rapidity of circulation is determined by the output of the heart. The performance of the heart and circula- 62 .
The amount of oxygen 63 . Each iron atom can bind and then release an oxygen molecule. transport of oxygen Oxygen is poorly soluble in plasma.2 ml of oxygen per ml of blood. Most oxygen is bound to hemoglobin. The quantity of oxygen bound to hemoglobin is dependent on the partial pressure of oxygen in the lung to which blood is exposed. The curve representing the content of oxygen in blood at various partial pressures of oxygen. important determinants of gas transport. In alveoli at sea level. Plasma. Enough hemoglobin is present in normal human blood to permit transport of about 0. the cell-free. therefore. Hemoglobin is composed of four iron-containing ring structures (hemes) chemically bonded to a large protein (globin). Not all of the oxygen transported in the blood is transferred to the tissue cells. Specialized systems for each gas have evolved to increase the quantities of those gases that can be transported in blood. Oxygen and carbon dioxide are too poorly soluble in blood to be adequately transported in solution. which make up 40 to 50 percent of the blood volume in most mammals. a protein contained within red cells. is a characteristic S-shape because binding of oxygen to one iron atom influences the ability of oxygen to bind to other iron sites. the partial pressure of oxygen is sufficient to bind oxygen to essentially all available iron sites on the hemoglobin molecule. These systems are present mainly in the red cells. so less than 2 percent of oxygen is transported dissolved in plasma. plays little role in oxygen exchange but is essential to carbon dioxide exchange.7 Gas Exchange and Respiratory Adaptation 7 tory regulation are. liquid portion of blood. called the oxygen-dissociation curve.
a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation). (Affinity denotes the tendency of molecules of different species to bind to one another. Although these substances do not bind to hemoglobin at the oxygen-binding sites. carbon dioxide. carbon dioxide. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. and 2. and 2. carbon dioxide. At rest. A rightward shift of the curve is thought to be of benefit in releasing oxygen to the tissues when needs are great in relation to oxygen delivery. as occurs with anemia or extreme exercise. Conversely. with the binding of oxygen.3-DPG decrease the affinity of hemoglobin for oxygen. including hydrogen ions (which determine the acidity. of the blood).) Increases in hydrogen ions. or pH. or 2. Hemoglobin binds not only to oxygen but to other substances as well. and the oxygen-dissociation curve shifts to the right. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances.3-diphosphoglycerate (2. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. Because of this decreased affinity.3-DPG result in an increased affinity of hemoglobin for oxygen. venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. This reserve is available to meet increased oxygen demands. and the curve is shifted 64 . an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin.3-DPG.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. Reductions in normal concentrations of hydrogen ions. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen.
A small portion of carbon dioxide. an insufficient time to eliminate all carbon dioxide. The range of body temperature usually encountered in humans is relatively narrow. so that temperature-associated changes in oxygen affinity have little physiological importance. principally hemoglobin. Furthermore. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion.7 Gas Exchange and Respiratory Adaptation 7 to the left. whereas a decrease in temperature shifts the curve to the left (increased affinity). Complete elimination would lead to large changes in acidity between arterial and venous blood. remains unchanged and is transported dissolved in blood. 65 . The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. as occurs at extreme altitude. 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. The remainder is found in reversible chemical combinations in red blood cells or plasma. enhanced release of oxygen). with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. blood normally remains in the pulmonary capillaries less than a second. transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex. Temperature changes affect the oxygen-dissociation curve similarly. An increase in temperature shifts the curve to the right (decreased affinity. 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. Some carbon dioxide binds to blood proteins.
As carbon dioxide enters the blood.7 The Respiratory System 7 Hemoglobin acts as a natural buffering agent for the acidity that occurs when carbon dioxide reacts with water.) The natural conversion of carbon dioxide to carbonic acid is a relatively slow process. a protein enzyme present inside the 66 . are effective buffering agents. (A buffer solution resists change in acidity by combining with added hydrogen ions and. which dissociates into hydrogen ions (H+) and bicarbonate ions (HCO3-). Shutterstock.com Carbon dioxide enters blood in the tissues because its local partial pressure is greater than its partial pressure in blood flowing through the tissues. especially hemoglobin. inactivating them. Carbonic anhydrase. a relatively weak acid. it combines with water to form carbonic acid (H2CO3 ). essentially. Blood acidity is minimally affected by the released hydrogen ions because blood proteins.
A few amino sites on hemoglobin are oxylabile. The bulk of bicarbonate ions is first produced inside the cell. Oxygenation of hemoglobin in the lungs has the reverse effect and leads to carbon dioxide elimination. catalyzes this reaction with sufficient rapidity that it is accomplished in only a fraction of a second.7 Gas Exchange and Respiratory Adaptation 7 red blood cell. The change in molecular configuration of hemoglobin that accompanies the release of oxygen leads to increased binding of carbon dioxide to oxylabile amino groups. The simultaneous exchange of these two ions. permits the plasma to be used as a storage site for bicarbonate without changing the electrical charge of either the plasma or the red blood cell. The 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. Only 5 percent of carbon dioxide in the blood is transported free in physical solution without chemical change 67 . Thus. Hemoglobin acts in another way to facilitate the transport of carbon dioxide. where the partial pressure of carbon dioxide is lower than in the blood. A reverse sequence of reactions occurs when blood reaches the lung. release of oxygen in body tissues enhances binding of carbon dioxide as carbamate. Only 26 percent of the total carbon dioxide content of blood exists as bicarbonate inside the red blood cell. their ability to bind carbon dioxide depends on the state of oxygenation of the hemoglobin molecule. Amino groups of the hemoglobin molecule react reversibly with carbon dioxide in solution to yield carbamates. however. while 62 percent exists as bicarbonate in plasma. then transported to the plasma. that is. Because the enzyme is present only inside the red blood cell. bicarbonate accumulates to a much greater extent within the red cell than in the plasma. known as the chloride shift.
most carbon dioxide is transported as bicarbonate or carbamate. yet this pool is important. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. Under ideal circumstances. partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. 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. In contrast to the cyclic nature of ventilation. and almost all blood entering the lungs participates in gas exchange. In health. gas exchange in the lung The introduction of air into the alveoli allows the removal of carbon dioxide and the addition of oxygen to venous blood. because only free carbon dioxide easily crosses biologic membranes. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. The lower parts of the lung receive slightly more blood flow than ventilation because gravity has a greater effect on the distribution of blood than on the distribution of inspired air. blood flow through the lung is continuous. Between these two events. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 .7 The Respiratory System 7 or binding. 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. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. not all inspired air participates in gas exchange.
shunting. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. A reduction in arterial blood oxygenation is seen with shunting. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs. venous blood enters the bloodstream without passing through functioning lung tissue. Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation.g.7 Gas Exchange and Respiratory Adaptation 7 gravity on matching and the addition of a small amount of venous drainage to the bloodstream after it has left the lungs. but the level of carbon dioxide in arterial blood is not elevated even 69 . ventilation– blood flow imbalance. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. alveoli filled with fluid or inflammatory material). and limitations of diffusion.. impaired oxygen exchange is far more common than impaired carbon dioxide exchange. Because of the differences in oxygen and carbon dioxide transport. In shunting. This abnormality leads to parallel changes in both gas and blood and is the only abnormality in gas exchange that does not cause an increase in the normally small difference between arterial and alveolar partial pressures of oxygen. 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.
7 The Respiratory System 7 though the shunted blood contains more carbon dioxide than arterial blood. 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. When blood perfusing the collapsed. the oxygen-dissociation curve is S-shaped and plateaus near the normal alveolar oxygen partial pressure. and the composite arterial blood carbon dioxide content remains normal. The remaining healthy portion of the lung receives both its usual ventilation and the ventilation that normally would be directed to the abnormal lung. Because the carbon dioxide–dissociation curve is steep and relatively linear. The lower carbon dioxide content in this blood counteracts the addition of blood with a higher carbon dioxide content from the abnormal area. As noted earlier. which is usually achieved without difficulty. unventilated area of the lung leaves the lung without exchanging oxygen or carbon dioxide. compensation for decreased carbon dioxide exchange in one portion of the lung can be counterbalanced by increased excretion of carbon dioxide in another area of the lung. This compensatory mechanism is less efficient than normal carbon dioxide exchange and requires a modest increase in overall ventilation. shunting of venous blood has a substantial effect on arterial blood oxygen content and partial pressure. In contrast. the content of carbon dioxide is greater than the normal carbon dioxide content. but the carbon dioxide–dissociation curve is steeper and does not plateau as the partial pressure of carbon dioxide increases. Blood leaving an unventilated area of the lung has 70 . As a result. blood leaving the healthy portion of the lung has a lower carbon dioxide content than normal. This lowers the partial pressure of carbon dioxide in the alveoli of the normal area of the lung.
and an increase in blood partial pressure results in a negligible increase in oxygen content. Thus. In alveoli that are overventilated. the amount of carbon dioxide eliminated is increased. however. cannot compensate in terms of greater oxygenation for underventilated alveoli because. As matching of inspired air and blood flow deviates from the normal ratio of 1 to 1. the increase in ventilation above normal raises the partial pressure of oxygen in the alveolar gas and.7 Gas Exchange and Respiratory Adaptation 7 an oxygen content that is less than the normal content. reaches a plateau at the normal alveolar partial pressure. Inspired air and blood flow normally are distributed uniformly. in the arterial blood. There are minimal changes in blood carbon dioxide content unless the degree of mismatch is extremely severe. which counteracts the fact that there is less carbon dioxide eliminated in the alveoli that are relatively underventilated. and each alveolus receives approximately equal quantities of both. In the healthy area of the lung. alveoli become either overventilated or underventilated in relation to their blood flow. Mismatching of ventilation and blood flow is by far the most common cause of a decrease in partial pressure of oxygen in blood. The oxygen-dissociation curve. however. 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. a plateau is reached at the 71 . 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. Overventilated alveoli. therefore.
loss of surface area available for diffusion of oxygen. For oxygen. These factors are usually grouped under the broad description of “diffusion limitation. In disease. however.” and any can cause incomplete transfer of oxygen with a resultant reduction in blood oxygen content. Any deviation from the usual clustering around the ratio of 1 to 1 leads to decreased blood oxygenation: the more disparate the deviation. and decreased time available for exchange due to increased velocity of flow. 72 . 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. is not affected by an abnormal ratio of ventilation and blood flow as long as the increase in ventilation that is required to maintain carbon dioxide excretion in overventilated alveoli can be achieved. A variety of processes can interfere with this orderly exchange.7 The Respiratory System 7 alveolar partial pressure of oxygen. In healthy lungs there is a narrow distribution of the ratio of ventilation to blood flow throughout the lung that is centred around a ratio of 1 to 1. Carbon dioxide exchange. and increased ventilation will not increase blood oxygen content. the greater the reduction in blood oxygenation. these include increased thickness of the alveolar–capillary membrane. There is no diffusion limitation of the exchange of carbon dioxide because this gas is more soluble than oxygen in the alveolar–capillary membrane. which facilitates carbon dioxide exchange. A fourth category of abnormal gas exchange involves limitation of diffusion of gases across the thin membrane separating the alveoli from the pulmonary capillaries. The complex reactions involved in carbon dioxide transport proceed with sufficient rapidity to avoid being a significant limiting factor in exchange.
cells set the demand for oxygen uptake and carbon dioxide discharge. This involves transport of oxygen from the lung to the tissues by means of the circulation of blood. Each cell maintains a set of furnaces. a molecule with only two phosphate bonds. circulation. For gas exchange that takes place in the lungs. which set the limit for respiration. To recharge the molecule by adding the third phosphate group requires energy derived from 73 . the heart was regarded as a furnace where the “fire of life” kept the blood boiling. In antiquity and the medieval period. whose third phosphate bond can release a quantum of energy to fuel many cell processes. The circulation of the blood links the sites of oxygen use and uptake. ATP is degraded to adenosine diphosphate (ADP). In the process. through the oxidation of foodstuffs such as glucose. and metabolism is the key to the functioning of the respiratory system as a whole. Modern cell biology has unveiled the truth behind the metaphor. Cell metabolism depends on energy derived from high-energy phosphates such as adenosine triphosphate (ATP). the energetic needs of the cells are supplied.7 Gas Exchange and Respiratory Adaptation 7 interplay of respiration. the mitochondria. The main purpose of respiration is to provide oxygen to the cells at a rate adequate to satisfy their metabolic needs. where. The precise object of respiration therefore is the supply of oxygen to the mitochondria. and MetabolisM The interplay of respiration. The proper functioning of the respiratory system depends on both the ability of the system to make functional adjustments to varying needs and the design features of the sequence of structures involved. circulation. such as the contraction of muscle fibre proteins or the synthesis of protein molecules.
aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. because the cells maintain only a limited store of highenergy phosphates and of oxygen. transferred to blood in the lungs. and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. many cells. whereas they usually have a reasonable supply of substrates in stock. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. In contrast. aerobic metabolism. anaerobic glycolysis. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. Because oxidative phosphorylation occurs only in mitochondria. Oxygen is collected from environmental air. will die. For any sustained highlevel cell activity. or fermentation.7 The Respiratory System 7 the breakdown of foodstuffs. Two pathways are available: 1. and 2. or even the organism. and since each cell must produce its own ATP (it cannot be imported). 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. If oxygen supply is interrupted for a few minutes. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. the aerobic metabolic pathway is therefore preferable. or substrates. It begins with 74 . The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. which requires oxygen and involves the mitochondria. which operates in the absence of oxygen. or its need for oxygen.
In the most peripheral airways. Convective transport by the blood depends on the blood flow rate (cardiac output) and on the oxygen capacity of the blood. which is determined by its content of hemoglobin in the red blood cells. which is bound to hemoglobin in the red blood cells.5 micrometre) and the surface area of the barrier. which is achieved by convection or mass flow of air through an ingeniously branched system of airways. the demand for ATP and oxygen increases linearly with work rate. a human consumes about 250 ml of oxygen each minute. ventilation of alveoli is completed by diffusion of oxygen through the air to the alveolar surface. more accurately the metabolic rate of the cells. but a highly trained athlete may achieve a more than 20-fold increase. Blood also serves as carrier for both respiratory gases: oxygen. As more and more muscle cells become engaged in doing work. With exercise this rate can be increased more than 10-fold in a normal healthy individual. and carbon dioxide. which is driven by the oxygen partial pressure difference and depends on the quantity of capillary blood in the tissue. and discharge to the cells. It is driven by the oxygen partial pressure difference between alveolar air and capillary blood and depends on the thickness (about 0. transport by blood flow. and by 75 .7 Gas Exchange and Respiratory Adaptation 7 ventilation of the lung. In this process the blood plays a central role and affects all transport steps: oxygen uptake in the lung. essentially resulting from a higher heart rate. This is accompanied by an increased cardiac output. At rest. Metabolism. The last step is the diffusive discharge of oxygen from the capillaries into the tissue and cells. or. 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. sets the demand for oxygen. The transfer of oxygen from alveolar air into the capillary blood occurs by diffusion across the tissue barrier.
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. Much has been learned from comparative physiology and morphology. mainly lactic acid. but rather by the limited ability of the respiratory system to provide or use oxygen at a higher rate. Consequently. because of the complexity of the system. Muscle can do more work. the oxygen partial pressure difference across the air–blood barrier increases and oxygen transfer by diffusion is augmented. the aerobic scope can be increased by training in an individual. oxygen consumption per unit body mass increases as animals become smaller. but it is not straightforward. such as dogs or horses. so that a mouse consumes six times as much oxygen per gram of body mass as a cow. based on observations that oxygen consumption rates differ significantly among species. Then. with the result that waste products. but beyond the aerobic scope they must revert to anaerobic metabolism. For example. this is called adaptive variation. accumulate and limit the duration of work.7 The Respiratory System 7 increased ventilation of the lungs. the athletic species in nature. 76 . Knowing precisely what sets the limit is important for understanding respiration as a key vital process. have an aerobic scope more than twofold greater than that of other animals of the same size. Furthermore. a feature called allometric variation. This range of possible oxidative metabolism from rest to maximal exercise is called the aerobic scope. The upper limit to oxygen consumption is not conferred by the ability of muscles to do work. The limit to oxidative metabolism is therefore set by some features of the respiratory system. but this induced variation achieves at best a 50 percent difference between the untrained and the trained state. from the lung to the mitochondria. well below interspecies differences.
in all types of variation. and they seem able to consume up to five millilitres of oxygen per minute and gram of mitochondria. The total amount of mitochondria in skeletal muscle is strictly proportional to maximal oxygen consumption. 77 . If energy (ATP) needs to be produced at a higher rate. the mitochondria increase in proportion to the augmented aerobic scope. Shutterstock. This difference arises from a phenomenon known as adaptive variation. cardiac output is augmented by increasing heart rate. In training. For example.7 Gas Exchange and Respiratory Adaptation 7 Athletic animals such as dogs have an aerobic scope more than twice that of similarly sized animals. Mounting evidence indicates that the limit to oxidative metabolism is related to structural design features of the system. the muscle cells make more mitochondria.com Within the aerobic scope the adjustments are caused by functional variation. Mitochondria set the demand for oxygen.
It appears. The issue of peripheral versus central limitation is still under debate.7 The Respiratory System 7 It is thus possible that oxygen consumption is limited at the periphery. But. whereas the mitochondria. rate. beyond which oxidative metabolism cannot be increased by training. the lung may well constitute the ultimate limit for the respiratory system. mainly the heart. 78 . the structure of the alveoli in the lungs. however. But it is also possible that more central parts of the respiratory system may set the limit to oxygen transport. 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 lung lacks this capacity to adapt. the blood vessels. In the cases of swimming and diving. or volume to augment their capacity when energy needs increase. whose capacity to pump blood reaches a limit. such as in training. adaptations Adaptation of the respiratory system to different atmospheric pressures plays a fundamental role in maintaining the efficiency of gas exchange and gas transport in the blood. In the case of adaptation to high altitudes. and the heart can increase in number. at the last step of aerobic metabolism. and the structure and function of the energy-producing mitochondria in the cells of tissues may be affected. the levels of hemoglobin in the blood. If this proves true. both in terms of rate and of the size of the ventricles. physiological changes are more acute in nature and are influenced by the immediate affects of decreased ventilation or by the affects of increased hydrostatic pressure on the body. the blood.
which. Humans and some other mammalian species. such as cattle. hikers and climbers acclimatize to low oxygen levels by using oxygen canisters. whether undertaken deliberately or not. The progressive fall in barometric pressure is accompanied by a fall in the partial pressure of oxygen.7 Gas Exchange and Respiratory Adaptation 7 High Altitudes Ascent from sea level to high altitude has well-known effects on respiration. Barry C. Bishop/National Geographic/Getty Images 79 . adjust to the fall in oxygen pressure through the reversible and non-inheritable process of acclimatization. which heighten the partial pressure of oxygen at all stages. Indigenous mountain species such as the At high altitudes. This very fall poses the major respiratory challenge to humans at high altitude. commences from the time of exposure to high altitudes. both in the ambient air and in the alveolar spaces of the lung.
attached to the division of the carotid arteries on either side of the neck. Respiratory acclimatization in humans is achieved through mechanisms that heighten the partial pressure of oxygen at all stages.3DPG. The scarcity of oxygen at high altitudes stimulates increased production of hemoglobin and red blood cells. the carotid bodies enlarge but become less sensitive to the lack of oxygen. which also shortens the diffusion path of oxygen. which increases the amount of oxygen transported to the tissues. the length of the diffusion path along which gases must pass is decreased—a factor augmenting gas exchange. on the other hand. In addition. Diffusion of oxygen across the alveolar walls into the blood is facilitated. as capillary density is increased. the carotid bodies. With a prolonged stay at altitude. which takes the form of deeper breathing rather than a faster rate at rest. As the oxygen deprivation persists. where oxygen is needed for the ultimate biochemical expression of respiration. The decline in the ambient partial pressure of oxygen is offset to some extent by greater ventilation. The extra oxygen is released by increased levels of inorganic phosphates in the red blood cells. The initial response of respiration to the fall of oxygen partial pressure in the blood on ascent to high altitude occurs in two small nodules. The low oxygen partial pressure in the lung is associated with thickening of the small blood vessels in pulmonary alveolar walls and a slight increase in pulmonary blood pressure. 80 . and in some experimental animal studies the alveolar walls are thinner at altitude than at sea level. from the alveolar spaces in the lung to the mitochondria in the cells. exhibit an adaptation that is heritable and has a genetic basis. and. the size of muscle fibres decreases.7 The Respiratory System 7 llama. the tissues develop more blood vessels. such as 2. thought to enhance oxygen perfusion of the lung apices.
some highlanders lose this acclimatization and develop chronic mountain sickness. including humans. This disease is characterized by greater levels of hemoglobin. either artificially induced (as by hyperventilation) or resulting from pressure changes in the environment at the 81 . A chemodectoma. alpaca. In Tibet some infants of Han origin never achieve satisfactory acclimatization on ascent to high altitude. sometimes called Monge disease. all vertebrates. exhibit a set of responses that may be called a “diving reflex. adapted mountain species do not have increased levels of hemoglobin or of organic phosphates in the red cells. After living many years at high altitude. and their carotid bodies remain small. Nevertheless.” which involves cardiovascular and metabolic adaptations to conserve oxygen during diving into water. They do not develop small muscular blood vessels or an increased blood pressure in the lung. Native human highlanders are acclimatized rather than genetically adapted to the reduced oxygen pressure. of the carotid bodies may develop in native highlanders in response to chronic exposure to low levels of oxygen. after the Peruvian physician who first described it. so full saturation of the blood with oxygen occurs at a lower partial pressure of oxygen. Swimming and Diving Fluid is not a natural medium for sustaining human life after the fetal stage. and vicuña in the Andes or the yak in the Himalayas are adapted rather than acclimatized to the low oxygen partial pressures of high altitude. Their hemoglobin has a high oxygen affinity. Other physiological changes are also observed. these indigenous. or benign tumour. In contrast to acclimatized humans.7 Gas Exchange and Respiratory Adaptation 7 Indigenous mountain animals like the llama. Human respiration requires ventilation with air.
When the accumulated carbon dioxide at last forces the swimmer to return to the surface. may be used intentionally by swimmers to prolong the time they are able to hold their breath underwater. the absolute pressure. a form of overbreathing that increases the amount of air entering the pulmonary alveoli. many of them unique in human physiology. as sometimes happens in snorkeling. The increased ventilation prolongs the duration of the breath-hold by reducing the carbon dioxide pressure in the blood. Most hazards result from the environmental pressure of water. Hyperventilation. however. But this apparent advantage introduces additional hazards. Divers who breathe from an apparatus that delivers gas at the same pressure as that of the surrounding water need not return to the surface to breathe and can remain at depth for prolonged periods. which is 82 . but it cannot provide an equivalent increase in oxygen. and consciousness remains unimpaired. Thus the carbon dioxide that accumulates with exercise takes longer to reach the threshold at which the swimmer is forced to take another breath. the progressively diminishing pressure of the water on his ascent reduces the partial pressure of the remaining oxygen.7 The Respiratory System 7 same time that a diver is breathing from an independent gas supply. Two factors are involved. and this danger is greatly increased if the swimmer descends to depth. This allows an adequate oxygen partial pressure to be maintained in the setting of reduced oxygen content. Hyperventilation can be dangerous. Unconsciousness may then occur in or under the water. At the depth of a diver. The increased environmental pressure of the water around the breath-holding diver increases the partial pressures of the pulmonary gases. but the oxygen content of the blood concurrently falls to unusually low levels.
the use of underwater breathing apparatus adds significant external breathing resistance to the diver’s respiratory burden. Alveolar oxygen levels can also be disturbed in diving. The effects of pressure are seen in many processes at the molecular and cellular level and include the physiological effects of the increased partial pressures of the respiratory gases. This may be compounded by an increased inspiratory content of carbon dioxide. often with the formation of bubbles. is the vertical hydrostatic pressure gradient across the body. 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. but the impaired alveolar ventilation at depth leads to some carbon dioxide retention (hypercapnia).7 Gas Exchange and Respiratory Adaptation 7 approximately one additional atmosphere for each 10-metre (33-foot) increment of depth. More commonly. the blood and tissues of the diver. Hypoxia may result from failure of the gas supply and may occur without warning. the effect of changes of pressure upon the volumes of the gas-containing spaces in the body. Although the increased work of breathing may largely result from the effects of increased respiratory gas density upon pulmonary function. the increased density of the respiratory gases. acting at any depth. especially if the diver uses closed-circuit and semiclosed-circuit rebreathing equipment or wears an inadequately ventilated helmet. rather than cardiac or muscular performance. The increased work of breathing. and the consequences of the uptake of respiratory gases into. is one factor. The other factor. Arterial carbon dioxide pressure should remain unchanged during changes of ambient pressure. is the limiting factor for hard physical work underwater. and their subsequent elimination from. the levels of inspired oxygen are 83 .
The use of hydrogen. High values of end-tidal carbon dioxide with 84 . which in a mixture with less than 4 percent oxygen is noncombustible.7 The Respiratory System 7 increased. 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 term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. In mixed-gas diving. like an anesthetic. has the additional advantage of providing a breathing gas of lesser density. approximately in proportion to the reciprocal of the square root of the increasing gas density.2 and 0. Oxygen in excess can be a poison. At a partial pressure greater than 1. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. inspired oxygen is therefore maintained at a partial pressure somewhere between 0. it may cause the rapid onset of convulsions. 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.5 bar. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. At the extreme depths now attainable by humans— some 500 metres (1.5 bar (“surface equivalent value” = 150 percent). and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. provides a greater respiratory advantage for deep diving.640 feet) in the sea and more than 680 metres (2.
The supporting effect of the surrounding water pressure upon the soft tissues promotes venous return from vessels no longer solely influenced by gravity. Nitrogen narcosis is enhanced by the presence of excess carbon dioxide. resulting in less intrathoracic blood volume. if it occurs underwater. The extra-alveolar gas may cause a “burst lung” (pneumothorax) or the tracking of gas into the tissues of the chest (mediastinal emphysema). in which case more blood will be shifted into the thorax. More seriously. And whatever the orientation of the diver in the water. Unless vented. the escaped alveolar gas may be carried by the blood circulation to the brain (arterial gas embolism). Intrathoracic pressure may be effectively lower than the pressure of the surrounding water. this approximates the effects of recumbency upon the cardiovascular and respiratory systems. places the diver at great risk. possibly extending into the pericardium or into the neck. Independent of the depth of the dive are the effects of the local hydrostatic pressure gradient upon respiration. which represents the net effect of the external pressures and the effects of chest buoyancy. This is a major cause of death among divers. Also. Failure to exhale 85 . and the physical properties of carbon dioxide facilitate the nucleation and growth of bubbles on decompression. has proved useful in designing underwater breathing apparatuses. the uniform distribution of gas pressure within the thorax contrasts with the hydrostatic pressure gradient that exists outside the chest. a condition that. The concept of a hydrostatic balance point within the chest. or it may be effectively greater. Intrapulmonary gas expands exponentially during the steady return of a diver toward the surface. the expanding gas may rupture alveolar septa and escape into interstitial spaces.7 Gas Exchange and Respiratory Adaptation 7 only moderate exertion may be associated with a diminished tolerance to oxygen neurotoxicity.
7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent. even from depths as shallow as 2 metres (6. 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. 86 . 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.6 feet). can result in a sometimes life-threatening condition known as decompression sickness. Inadequacy of diver decompression. which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure.
Thus. whether of the upper or lower respiratory tract. and tuberculosis.CHAPTER4 INFECTIOUS DISEASES OF THE RESPIRATORY SYSTEM I nfectious diseases are among the most common conditions affecting the human respiratory system. upper respiratory infections include the common cold. and tonsillitis. and molds. bacteria. tracheitis. Some conditions can cause extensive lung damage. resulting in patient isolation. however. These diseases may be caused by a variety of agents. as considered here. and may be highly contagious. with this division occurring at the anatomical level of the larynx. various types of pneumonia. this distinction is complicated by the fact that diseases of the upper tissues can spread to the lower tissues. can be effectively treated with prescription antimicrobial drugs. including viruses. whereas lower respiratory infections include laryngitis. pharyngitis. Examples of severe lower respiratory infections include croup. Other treatments may include the intravenous administration of fluids and of medications that cannot be taken orally. Legionnaire disease. sinusitis. However. In most cases. 87 . and any condition of the bronchi and lungs. Infectious respiratory diseases can be divided into those that affect the upper respiratory tract and those that affect the lower respiratory tract. requiring patient hospitalization. infectious diseases.
Some of these infections may resolve on their own. The popular term common cold reflects the feeling of chilliness on exposure to a cold environment that is part of the onset of symptoms. but this is now known to be incorrect. respiratory syncytial viruses. usually one to four days. with little or no medication. or drafts. and tonsils are frequently the site of both acute and chronic infections. sometimes spreads to the lower respiratory structures. and may cause secondary infections in the eyes or middle ears. In other cases. however. The feeling was originally believed to have a cause-and-effect relationship with the disease. More than 200 agents can cause symptoms of the common cold. Incubation is short. The viruses start spreading from an infected person before the symptoms appear. and the 88 .7 The Respiratory System 7 upper respiratory systeM infections The nasal sinuses. an infection that spreads to the tissues of the lower respiratory tract may give rise to debilitating illness that requires extensive medical intervention. including parainfluenza. and some 100 different strains of rhinoviruses have been associated with coldlike illness in humans. not from a cold environment. influenza. The cold is caught from exposure to infected people. and reoviruses. are the most frequent cause. People can carry the virus and communicate it without experiencing any of the symptoms themselves. however. chilled wet feet. Rhinoviruses. pharynx. These conditions occur in both children and adults and are readily spread through exposure to infected individuals. Common Cold The common cold is an acute viral infection that starts in the upper respiratory tract.
The nasal discharge is the first warning that one has caught a cold. fatigue. coughing is added to the infected person’s symptoms in a further effort to get rid of the virus. Cold symptoms vary from person to person. Symptoms may include sneezing. The incidence of colds peaks during the autumn. chills. the clear fluid often changing to a thick.7 Infectious Diseases of the Respiratory System 7 spread reaches its peak during the symptomatic phase. headaches. There is usually no fever. and nasal discharge. a second method of expelling the virus. There is no effective antiviral agent available for the common 89 . which increases the likelihood of close contact with those persons carrying cold viruses. but it is possible to take a culture for viruses. thereby setting up sneezing. Once a virus becomes established on the respiratory surface of the nose. Coughing can be dry or produce amounts of mucus. yellow-green fluid that is full of the debris of dead cells. Young children can contract between three and eight colds a year. This fluid acts to dilute the virus and clear it from the nose. which respond by pouring out streams of clear fluid. The sensory organs in the nose are stung by the inflammatory reaction. but in the individual the same symptoms tend to recur in succeeding bouts of infection. but the reason for this incidence is unknown. usually coming into contact with the infectious agents in day care centres or preschools. Symptoms abate as the host’s defenses increase. but lingering cough and postnasal discharge may persist for two weeks or more. Diagnosis of a cold is usually made by medical history alone. The usual duration of the illness is about five to seven days. its activities irritate the nose’s cells. and minor epidemics commonly occur throughout the winter. If the virus penetrates more deeply into the upper respiratory tract. It may result from the greater amount of time spent indoors. inflammation of the nose (rhinitis). sore throat.
and nasal discharge. chills. sore throat. fatigue.com 90 . rhinitis. but it can comprise sneezing. the common cold does not involve a fever. headaches.7 The Respiratory System 7 Usually. Shutterstock.
which typically subside after one week. mycoplasmas. For a viral sore throat. Inflammation usually involves the nasopharynx. and the tonsils may secrete pus and become swollen. uvula. and parasites and by recognized diseases of uncertain causes. treatment is aimed at relieving symptoms. A sore throat may be a symptom of influenza or of other respiratory infections. as are antiseptic gargles. fungi. In treating nonviral sore throat. a result of irritation by foreign objects or fumes. Generally. Sore Throat Sore throat is a painful inflammation of the passage from the mouth to the pharynx or of the pharynx itself (pharyngitis). 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. Therapy consists of treating the symptoms: relieving aches. the throat reddens. The illness can be caused by bacteria.7 Infectious Diseases of the Respiratory System 7 cold. soft palate. In many studies. antibiotics are often effective. Pharyngitis Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the pharynx. fever. and tonsils. administration of ascorbic acid has failed to prevent or decrease the symptoms of the common cold. or a reaction to certain drugs. Infection by 91 . viruses. One of the greatest medical controversies in the past few decades has concerned the efficacy of vitamin C (ascorbic acid) in the prevention or treatment of the common cold. Infections caused by a strain of streptococcal bacteria and viruses are often the primary cause of a sore throat. and nasal congestion.
Within approximately three days the fever leaves. Purulent (pus-producing) sinusitis can occur. appropriate antibiotic therapy. usually with penicillin. diphtheria. including tuberculosis. a pustulant fluid on the tonsils or discharged from the mouth. Usually only the symptoms can be treated: throat lozenges control sore throat and acetaminophen or aspirin control fever. The symptoms of streptococcal pharyngitis (commonly known as strep throat) are generally redness and swelling of the throat. is instituted. Viral pharyngitis infections also occur. and meningitis. nausea. They can produce raised whitish to yellow lesions in the pharynx that are surrounded by reddened tissue. however. Sinusitis Sinusitis is acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses (the cavities in the bones that adjoin the nose). syphilis. headache. requiring treatment with antibiotics. and irritability. swelling of lymph nodes. and sore throat that last for 4 to 14 days. sometimes in children there are abdominal pain. Chronic cases caused by irritants in the environment or by 92 . and a slight fever. but the other symptoms may persist for another two to three days. Sinusitis commonly accompanies upper respiratory viral infections and in most cases requires no treatment. extremely sore throat that is felt during swallowing. and the cause of pharyngeal inflammation can be determined by throat culture. If a diagnosis of streptococcal infection is established by culture.7 The Respiratory System 7 Streptococcus bacteria may be a complication arising from a common cold. headache. They cause fever. A number of other infectious diseases may cause pharyngitis. Lymphatic tissue in the pharynx may also become involved. Diagnosis is established by a detailed medical history and by physical examination.
and many other penicillin-sensitive anaerobes. and sinus tenderness. keeping the sinuses clean. Diagnosis can be confirmed by X-rays of the sinuses and cultures of material obtained from within the sinuses. Normally the middle ear and the sinuses are sterile. infection can be established. 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. On physical examination. the pus localized in any individual sinus may have to be removed by means of a minor surgical procedure known as lavage. The origin of acute sinus infection is much like that of ear infection. If the infection persists. Streptococcus pyogenes. Under normal conditions. Staphylococcus aureus. Common symptoms include facial pain. but the adjacent mouth and nose have a varied bacterial flora.7 Infectious Diseases of the Respiratory System 7 impaired immune systems may require more extended treatment. When ciliary function is damaged. very small hairs called cilia move mucus along the lining of the nose and respiratory tract. 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. nasal discharge. It may also be caused by allergy to agents 93 . Following a common cold. particularly if impaired breathing or drainage result from nasal polyps or obstructed sinus openings. 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 pneumoniae. including surgery. and fever following previous upper respiratory viral illness. in which the maxillary or sphenoidal sinuses are irrigated with water or a saline solution. headache.
More serious are two distant complications— acute nephritis (kidney inflammation) and acute rheumatic fever. difficulty in swallowing. Locally. The complications of acute streptococcal tonsillitis are proportional to the severity of the infection. Repeated acute infections may cause chronic inflammation of the tonsils. such as fungi or pollen. In severe cases endoscopic surgery may be necessary to remove obstructions. The symptoms of chronic sinusitis are a tendency to colds. evidenced by tonsillar enlargement. malaise.7 The Respiratory System 7 in the environment. resulting in a peritonsillar abscess. trachea. isolation to protect others from the infection. loss of smell. The infection may extend upward into the nose. The 94 . and warm throat irrigations or gargles with a mild antiseptic solution. The infection lasts about five days. The symptoms are sore throat. and swollen lymph nodes in the neck. virulent bacteria may spread from the infected tonsil to the adjoining tissues. steroidal medications may be given to relieve swelling and antihistamines to relieve allergic reactions. sinuses. Tonsillitis Tonsillitis is an inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms. Antibiotics or sulfonamides or both are prescribed in severe infections to prevent complications. and enlarged lymph nodes on both sides of the neck. usually hemolytic streptococci or viruses. fever. If antibiotic therapy or repeated lavage do not alleviate the condition. and sometimes headache. Pain is not a feature of chronic sinusitis. The treatment includes bed rest until the fever has subsided. purulent nasal discharge. obstructed breathing. repeated or persistent sore throat. and ears or downward into the larynx. and bronchi. with or without heart involvement.
Likewise. which can be caused by bacterial or viral infection or which may arise secondary to some other condition. diphtheritic. lower respiratory systeM infections Infections of the lower respiratory system represent some of the most frequently occurring life-threatening conditions. in trench mouth. or syphilitic. is associated with a high rate of death in infants and the elderly. In diphtheria the tonsils are covered with a thick. Laryngitis Laryngitis is an inflammation of the larynx that is caused by chemical or mechanical irritation or by bacterial infection. Thus. whitish. diphtheria. Simple laryngitis is usually associated with the common cold or similar infections. the infectious disease tuberculosis. Usually the mucous membrane lining the larynx is the site of prime infection. For example. or sulfur dioxide can also cause severe inflammation. steam. pneumonia. and contains many 95 . adherent membrane. Laryngitis is classified as simple.7 Infectious Diseases of the Respiratory System 7 treatment in this case is surgical removal (tonsillectomy). secretes a thick mucous substance. Nonbacterial agents such as chlorine gas. It becomes swollen and filled with blood. can be exceptionally difficult to treat and may cause progressive respiratory dysfunction. tuberculous. in order to prevent potentially disabling damage to lung tissue. infectious diseases of the lower respiratory tissues sometimes require extensive medical attention. Scarlet fever. and trench mouth may also produce acute tonsillitis. with a grayish membrane that wipes off readily. which is a major cause of lung disease globally. involving long-term antimicrobial therapy.
becomes swollen and infected by influenza viruses. The scars can distort the larynx. In the second stage of syphilis. Tracheitis Tracheitis is an inflammation and infection of the trachea. Chronic laryngitis is produced by excessive smoking. Tubercular nodule-like growths are formed in the larynx tissue. It may cause a membrane of white blood cells. sores or mucous patches can form. small lumps of tissue that project from the surface. A similar type of membrane covering can occur in streptococcal infections. or overuse of the vocal cords. Diphtheritic laryngitis is caused by the spread of diphtheria from the region of the upper throat down to the larynx. The bacteria die after infecting the tissue. fibrin (blood clotting protein). Most conditions that affect the trachea are bacterial or 96 . Tuberculous laryngitis is a secondary infection spread from the initial site in the lungs. The wall of the larynx may thicken and become inflamed. and suffocation may result. alcoholism. When looser portions of this false membrane become dislodged from part of the larynx. As the disease advances to the third stage. When the epiglottis. Syphilitic laryngitis is one of the many complications of syphilis. The mucous membrane becomes dry and covered with polyps. leaving ulcers on the surface. which closes the larynx during swallowing.7 The Respiratory System 7 inflammatory cells. and diseased skin cells to attach to and infiltrate the surface mucous membrane. There may be eventual destruction of the epiglottis and laryngeal cartilage. the larynx can become obstructed. shorten the vocal cords. tissue destruction is followed by healing and scar formation. they may consolidate at the vocal cords and cause an obstruction there. and produce a permanent hoarseness of the voice.
and degeneration of the tracheal tissue can occur. Common bacterial causes of acute infections are pneumococci. Chronic infections recur over a number of years and cause progressive degeneration of tissue. smallpox. Degenerated tissue is eventually replaced by a fibrous scar tissue. and small polyplike formations occasionally grow. and syphilis all afflict the trachea. A false membrane composed of white blood cells and fibrin (clotting protein) coat the surface of the trachea. The mucous glands may become swollen. Blood vessels increase in number. Acute infections occur suddenly and usually subside quickly. hemorrhages. Diphtheria. sulfur dioxide. streptococci. and the walls thicken because of an increase in elastic and muscle fibres. Diphtheria usually involves the upper mouth and throat. and staphylococci. and dense smoke can injure the lining of the trachea and increase the likelihood of infections. and swelling of the mucous membrane lining the trachea. The walls of the trachea during chronic infection contain an excess of white blood cells. form in the mucous membrane.7 Infectious Diseases of the Respiratory System 7 viral infections. but the trachea may also be attacked. In smallpox. Tuberculosis causes nodules and ulcers that start on the membrane and progress through the tissue to the cartilage. Intense blood congestion. Typhoid causes swelling and ulceration in the lymph tissue. Infections may last for a week or two and then pass. tuberculosis. they do not cause significant damage to the tissue unless they become chronic. The cartilage deteriorates and sometimes breaks apart causing severe pain and swelling. pustules and ulcers. It can occasionally ulcerate the cartilage of the trachea and destroy tissue. The infections produce fever. such as those that occur on the external skin. Generally. Syphilis forms lesions that erode the 97 . although irritants like chlorine gas. Neisseria organisms. Irritants such as heavy smoking and alcoholism may invite infections. fatigue.
there is obstruction at the opening of the trachea. inflammation occurs around the bronchial tree. The symptoms are caused by inflammation of the laryngeal membranes. In cases of severe airway obstruction. the most frequent being those with the parainfluenza and influenza viruses. spasms of the laryngeal muscles. is a more serious condition that is often caused by Haemophilus influenzae type B. Bacterial croup. Generally. Because of the marked swelling of the epiglottis. with high fever and breathing difficulties. Croup Croup is an acute respiratory illness of young children that is characterized by a harsh cough. Viral infections are the most common cause of croup. hoarseness. It is characterized by marked swelling of the epiglottis. The onset is usually abrupt. It is most often caused by an infection of the airway in the region of the larynx and trachea. also called epiglottitis. and they strike most frequently in late fall and winter. the onset of viral croup is preceded by the symptoms of the common cold for several days.7 The Respiratory System 7 tissue. In some cases. a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. or inflammation around the trachea. Such infections are most prevalent among children younger than age three. making it necessary for the patient to sit and lean 98 . and can cause thickening and stiffening of the spaces between the cartilage. Some cases result from allergy or physical irritation of these tissues. and difficult breathing. Most children with viral croup can be treated at home with the inhalation of mist from an appropriate vaporizer. hospitalization may be necessary. Epinephrine and corticosteroids have also been used to reduce swelling of the airway.
Under certain circumstances. In addition. particularly in people who have underlying chronic lung disease. Acute bronchitis can also be caused by bacteria such as Streptococcus.7 Infectious Diseases of the Respiratory System 7 forward to maximize the airflow. Children with epiglottitis require prompt medical attention. through which air passes into the lungs. however. Patients are given antibiotics. Epiglottitis generally strikes children between ages three and seven. ammonia. It is most frequently caused by viruses responsible for upper respiratory infections. The most obvious symptoms are a sensation of chest congestion and a mucus-producing cough. resulting usually in a relatively brief disease called acute infectious bronchitis. it is sometimes precipitated by chemical irritants such as toxic gases or the fumes of strong acids. Acute infectious bronchitis is an episode of recurrent coughing and mucus production lasting several days to several weeks. An artificial airway must be opened. it is often part of the common cold and is a common sequel to influenza. Therefore. or organic solvents. preferably by inserting a tube down the windpipe. 99 . Under ordinary circumstances. the sensitive mucous membranes lining the inner surfaces of the bronchi are well protected from inhaled infectious organisms by the filtering function of the nose and throat and by the cough reflex. whooping cough. Infectious Bronchitis Infectious bronchitis is an inflammation of all or part of the bronchial tree (the bronchi). The occurrence of epiglottitis has decreased in the Western world owing to an effective vaccine against H. organisms do enter the airways and initiate a sudden and rapid attack. influenzae. and measles. which generally relieve the inflammation within 24 to 72 hours.
Steam inhalation. In adults. bronchodilators. repetitive condition. Bronchiolitis probably occurs to some extent in acute viral disorders. particularly in children between ages one and two. or this may develop slowly over time. discussed in a later chapter. and particularly in infections with respiratory syncytial virus. Bronchiolitis Bronchiolitis refers to inflammation of the small airways. which results in protracted and often permanent damage to the bronchial mucosa. acute exacerbations of infection are associated with further damage to small airways. called chronic bronchitis.7 The Respiratory System 7 Treatment of acute bronchitis is largely symptomatic and of limited benefit. and expectorants will usually relieve the symptoms. is a long-standing. In isolated cases. Bacterial acute bronchitis responds to treatment with an appropriate antibiotic. in whom such a syndrome may follow the acute exposure. 100 . In addition to patients acutely exposed to gases. In some cases the inflammation may be severe enough to threaten life. Another form of bronchitis. with complete healing in all but a very small percentage of cases. but it normally clears spontaneously. an acute bronchiolitis episode is followed by a chronic obliterative condition. acute bronchiolitis of this kind is not a well-recognized clinical syndrome. patients with rheumatoid arthritis may develop a slowly progressive obliterative bronchiolitis that may prove fatal. though there is little doubt that in most patients with chronic bronchitis. An obliterative bronchiolitis may appear after bone marrow replacement for leukemia and may cause shortness of breath and disability. This pattern of occurrence has only recently been recognized.
which may occur from inhaling gas in silos. and the lesion is an acute bronchiolitis. is characteristically not followed by acute symptoms. or in fires involving plastic materials. when welding in enclosed spaces such as boilers. An inflammation around the small airways. Monty Rakusen/Cultura/Getty Images Exposure to oxides of nitrogen. but a short cough and progressive shortness of breath may not be evident for hours. 101 . A chest radiograph shows patchy inflammatory change. after blasting underground. known as a respiratory bronchiolitis. These develop some hours later.7 Infectious Diseases of the Respiratory System 7 Welding in enclosed spaces often results in exposure to oxides of nitrogen. when the victim develops a short cough and progressive shortness of breath. is believed to be the earliest change that occurs in the lung in cigarette smokers. Symptomatic recovery may mask incomplete resolution of the inflammation.
often accompanied by irritation or a sense of rawness in the throat. The inflammation is probably reversible if smoking is discontinued. Influenza Influenza. with sudden and distinct chills. 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. after which the onset of symptoms is abrupt. and trachea. Transmission and Symptoms Influenza viruses are transmitted from person to person through the respiratory tract. The temperature rises rapidly to 38–40 °C (101–104 °F). chills. The flu may affect individuals of all ages. they selectively attack and destroy the ciliated epithelial cells that line the upper respiratory tract. fatigue. A diffuse headache and severe muscular aches throughout the body are experienced. The incubation period of the disease is one to two days.7 The Respiratory System 7 although it does not lead to symptoms of disease at that stage. and it is generally more frequent during the colder months of the year. is an acute viral infection of the upper or lower respiratory tract that is marked by fever. by such means as inhalation of infected droplets resulting from coughing and sneezing. bronchial tubes. and the person begins to recover. though the highest incidence of the disease is among children and young adults. together with varying degrees of soreness in the head and abdomen. In three to four days the temperature begins to fall. and muscle aches. Symptoms associated with respiratory tract 102 . also known simply as the flu (or grippe). As the virus particles gain entrance to the body. and a generalized feeling of weakness and pain in the muscles.
In order to prevent humaninfecting bird flu viruses from mutating into more 103 . was introduced in the late 1990s. routine immunization in healthy people is also recommended. standard commercial preparations ordinarily include the type B influenza virus and several of the A subtypes. However. a very serious illness. thereby reducing their effectiveness. Individual protection against the flu may be bolstered by injection of a vaccine containing two or more circulating influenza viruses. such as coughing and nasal discharge. as well as a strain of virus known as influenza type B. These viruses are produced in chick embryos and rendered noninfective. A newer category of drugs. and yearly vaccination may be recommended. these drugs inhibit influenza A. Protection from one vaccination seldom lasts more than a year. Other than this. particularly for those individuals who are unusually susceptible to influenza or whose weak condition could lead to serious complications in case of infection. become more prominent and may be accompanied by lingering feelings of weakness. viral resistance to these agents has been observed. ingestion of fluids. and the use of analgesics to control fever. which includes oseltamivir (Tamiflu) and zanamivir (Relenza). 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. as treatment of viral infections with aspirin is associated with Reye syndrome. However. the standard treatment remains bed rest. the neuraminidase inhibitors. Death may occur. and is caused in most of those cases by complications such as pneumonia or bronchitis. usually among older people already weakened by other debilitating disorders. It is recommended that children and teenagers with the flu not be given aspirin.7 Infectious Diseases of the Respiratory System 7 infection.
public health authorities try to limit the viral “reservoir” where antigenic shift may take place by ordering the destruction of infected poultry flocks. and decreases the spread of the virus through the body. Oseltamivir and a similar agent called zanamivir (marketed as Relenza) were approved in 1999 by the U.based pharmaceutical company Hoffman–La Roche. and decreases the spread of the virus through the body. Food and Drug Administration and represented the first members in a new class of antiviral drugs known as neuraminidase inhibitors. a glycoprotein on the surface of influenza viruses. increases the formation of viral aggregates. Zanamivir (Relenza) Zanamivir 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. Oseltamivir is marketed as Tamiflu by the U. the drug decreases the release of virus from infected cells. The drug can also be used to prevent flu in adults and children who take the medication once daily for a period of at least 10 days.7 The Respiratory System 7 dangerous subtypes. Oseltamivir can be given orally. Inc. Zanamivir is given by inhalation only. Through the inhibition of neuraminidase. By inhibiting the neuraminidase glycoprotein on the surface of the influenza virus.S. If taken within 30 hours of 104 .S. zanamivir decreases the release of virus from infected cells. known as H1N1. Oseltamivir (Tamiflu) Oseltamivir is an antiviral drug that is active against both influenza type A and influenza type B viruses. There is evidence that the most common subtype of influenza type A virus. It is sold under the trade name Relenza by the pharmaceutical company GlaxoSmithKline. increases the formation of viral aggregates. has developed resistance to oseltamivir.
the causative agent of whooping cough. highly communicable respiratory disease. zanamivir can shorten the duration of the illness.” The coughing ends with the expulsion of clear. Whooping cough is caused by the bacterium Bordatella pertussis. sticky mucus and often with vomiting. Bordetella pertussis. Centers for Disease Control and Prevention (CDC) (Image Number: 2121) 105 . when taken once daily for 10 to 28 days. or pertussis. is an acute. Zanamivir. or “whoop. can prevent influenza infection in some adults and children. Whooping Cough Whooping cough.7 Infectious Diseases of the Respiratory System 7 the onset of influenza. It is characterized in its typical form by paroxysms of coughing followed by a long-drawn inspiration. isolated and coloured with Gram stain.
It was first called the Bordet-Gengou bacillus. slowed or stopped breathing. and occasionally convulsions and indications of brain damage. later Haemophilus pertussis. the illness progresses through three stages—catarrhal. Now included in the DPT (diphtheria. and convalescent—which together last six to eight weeks. Immunization is routinely begun at two months of age and requires five shots for maximum 106 . and still later Bordetella pertussis. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. In the paroxysmal state. The disease was first adequately described in 1578. Catarrhal symptoms are those of a cold. and a low-grade fever. Whooping cough is worldwide in distribution and among the most acute infections of children. variable in duration but commonly lasting four to six weeks.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. tetanus. During the convalescent stage there is gradual recovery. undoubtedly it had existed for a long time before that. Beginning its onset after an incubation period of approximately one week. and pertussis) vaccine. red eyes. the name pertussis (Latin: “intensive cough”) was introduced in England. with a short dry cough that is worse at night. ear infections. About 100 years later. In 1906 at the Pasteur Institute. it confers active immunity against whooping cough to children. Complications of whooping cough include pneumonia. and be dazed and apathetic. The infected person may appear blue. there is a repetitive series of coughs that are exhausting and often result in vomiting. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. paroxysmal. but the periods between coughing paroxysms are comfortable. with bulging eyes. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease.
especially if they have been vaccinated in infancy. Treatment includes erythromycin. Sedatives may be administered to induce rest and sleep. attributed to contact with imported parrots. turkeys. from which the disease is named). occurred in 12 countries of Europe and America. parrots and parakeets (family Psittacidae. Infants with the disease require careful monitoring because breathing may temporarily stop during coughing spells. The diagnosis of the disease is usually made on the basis of its symptoms and is confirmed by specific cultures. and geese are the principal sources of human infection. The association between the human disease and sick parrots was first recognized in Europe in 1879. is an infectious disease of worldwide distribution caused by a bacterial parasite (Chlamydia psittaci) and transmitted to humans from various birds. The infection has been found in about 70 different species of birds. and another booster is given when the child is between four and six years old. also known as ornithosis (or parrot fever). and sometimes the use of an oxygen tent is required to ease breathing. when severe outbreaks. During the investigations conducted in Germany. an antibiotic that may help to shorten the duration of illness and the period of communicability. Later vaccinations are in any case thought to be unnecessary. although a thorough study of the disease was not made until 1929– 30. England. Psittacosis Psittacosis. the causative agent was revealed. because the disease is much less severe when it occurs in older children. pigeons. and the United States. ducks. Strict regulations followed concerning 107 .7 Infectious Diseases of the Respiratory System 7 protection. A booster dose of pertussis vaccine should be given between 15 and 18 months of age.
but it usually occurs in hospitalized persons who. but in humans it can be fatal if untreated. have reduced resistance to 108 . in particular species of Streptococcus and Mycoplasma. Fungal pneumonia can develop very rapidly and may be fatal. viruses more commonly play a part in weakening the lung. The infection was later found in domestic stocks of parakeets and pigeons and subsequently in other species. Many organisms. the case fatality rate was approximately 20 percent. which undoubtedly reduced the incidence of the disease but did not prevent the intermittent appearance of cases. Psittacosis usually causes only mild symptoms of illness in birds. because of impaired immunity. or irradiation. In humans psittacosis may cause high fever and pneumonia. Humans usually contract the disease by inhaling dust particles contaminated with the excrement of infected birds. can cause pneumonia. thus inviting secondary pneumonia caused by bacteria. inhalation of foreign particles. weakness. but the most common causes are bacteria. The bacterial parasite thus gains access to the body and multiplies in the blood and tissues. ducks. Before modern antibiotic drugs were available. and convalescence often is protracted. The typical duration of the disease is two to three weeks. but penicillin and the tetracycline drugs reduced this figure almost to zero.7 The Respiratory System 7 importation of psittacine birds. or geese have caused many cases among poultry handlers or workers in processing plants. and an elevated respiratory rate. including viruses and fungi. Although viral pneumonia does occur. head and body aches. Other symptoms include chills. Infected turkeys. Pneumonia Pneumonia is an inflammation and solidification of the lung tissue as a result of infection.
especially in hospitalized patients.g. As the disease progresses. Pneumonia can also occur as a hypersensitivity. chest pain. when inhaled by previously healthy individuals.7 Infectious Diseases of the Respiratory System 7 infection. caused by Streptococcus pneumoniae. The bacteria may live in the bodies of healthy persons and cause disease only after resistance has been lowered by other illness or infection. Viral infections such as the common cold promote streptococcal pneumonia by causing excessive secretion of fluids in the respiratory tract. to agents such as mold. In some cases. the illness may become very severe. Death from streptococcal pneumonia is caused by inflammation and significant and extensive bleeding in the lungs that results in the eventual cessation of breathing. These fluids provide an environment in which the bacteria flourish.. smoke inhalation). is the single most common form of pneumonia. and it is sometimes fatal. Sputum discharge may contain flecks of blood. can sometimes cause fungal lung diseases. Streptococcal bacteria release a toxin called pneumolysin that damages the blood vessels in the 109 . and recovery generally occurs in a few weeks. Contaminated dusts. and difficulty in breathing. Bacterial Pneumonia Streptococcal pneumonia. Patients with bacterial pneumonia typically experience a sudden onset of high fever with chills. Treatment is with specific antibiotics and supportive care. cough. Diagnosis usually can be established by taking a culture of the organism from the patient’s sputum and by chest X-ray examination. particularly in elderly people and young children. humidifiers. and animal excreta or to chemical or physical injury (e. coughing becomes the major symptom. Any chest pains result from the tenderness of the trachea (windpipe) and muscles from severe coughing. however. or allergic response.
caused by Mycoplasma pneumoniae. or nerves. Other bacterial pneumonias include Legionnaire disease. elastic fibres. which leads to the further release of pneumolysin. and influenza viruses. Mycoplasmal pneumonia. an atypical infectious form. and psittacosis. Klebsiella pneumoniae. although it has little ability to infect the lungs of healthy persons. usually affects children and young adults.7 The Respiratory System 7 lungs. Antibiotics may exacerbate lung damage because they are designed to kill the bacteria by breaking them open. produces a highly lethal pneumonia that occurs almost exclusively in hospitalized patients with impaired immunity. pneumonia secondary to other illnesses caused by Staphylococcus aureus and Hemophilus influenzae. few cases beyond age 50 are seen. Research into the development of aerosol agents that stimulate blood clotting and that can be inhaled into the lungs and possibly be used in conjunction with traditional therapies for streptococcal pneumonia is ongoing. an extremely small organism. although epidemics can occur. pneumoniae grows on the mucous membrane that lines the surfaces of internal lung structures. Symptoms of 110 . Most outbreaks of this disease are confined to families. parainfluenza. Another bacterium. Usually the organism does not invade the membrane that surrounds the lungs. M. The bacteria can produce an oxidizing agent that might be responsible for some cell damage. or institutions. but it does sometimes inflame the bronchi and alveoli. caused by Legionella pneumophilia. it does not invade the deeper tissues—muscle fibres. Viral and Fungal Pneumonia Viral pneumonias are primarily caused by respiratory syncytial. small neighbourhoods. causing bleeding into the air spaces.
and low-grade fever. old sheds or barns. decreased appetite. Nonbacterial pneumonia is treated primarily with supportive care. room humidifiers. and wood pulp may cause similar illnesses. Hypersensitivity Pneumonia Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. cough. headache. muscle pain. and doves may develop manifestations of hypersensitivity pneumonia. and skin testing is included in the initial examination of patients with lung problems. usually followed by respiratory congestion and cough. In addition. all of which may subside in a day if there is no further exposure. Tuberculosis should always be considered a possibility in any patient with pneumonia. Other fungi found in barley. particularly if the patient was recently exposed to excavations. Diagnosis is established by physical examination and chest X-rays. Initially. or other chronic diseases. These pneumonias may occur following exposure to moldy hay or sugarcane. AIDS. Pneumocystis carinii pneumonia has been one of the major causes of death among AIDS patients. pigeons. all of which contain the fungus Actinomyces. and air-conditioning ducts. Other fungal and protozoan parasites (such as Pneumocystis carinii ) are common in patients receiving immunosuppressive drugs or in patients with cancer. the prognosis is excellent. maple logs. In general. shortness of breath. these patients experience fever with chills. or dust storms.7 Infectious Diseases of the Respiratory System 7 these pneumonias include runny nose. gerbils. people exposed to rats. backyard swimming pools. A more insidious form of hypersensitivity pneumonia is 111 . Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered. parakeets. and malaise.
less often. and specific laboratory tests. and supportive care. it may come from the body itself when the lung is physically injured. weight loss. Treatment consists of removing the patient from the offending environment. are difficult to treat. for example. Oil that is being swallowed may be breathed into the respiratory tract. Patients with AIDS may develop pneumonia from cytomegalovirus or Pneumocystis infections. bed rest. Other Causes of Pneumonia Pneumonia can also result from inhalation of oil droplets. and may prove fatal. the patient was at risk for developing pneumonia from organisms or viruses not normally pathogenic. before organ transplantation to reduce the rate of rejection). fever. Diagnosis is established by medical history. or.) Recovery is usual unless too great an area of lung tissue is involved. Pneumonia in Immunocompromised Persons For some years prior to 1980. (The level of radiation in a routine chest X-ray is too low to cause significant damage to living tissue. known as lipoid pneumonia. This type of disease. Ordinarily no treatment is necessary.7 The Respiratory System 7 associated with persistent malaise. and cough. Inflammation of lung tissues may result from X-ray treatment of tumours within the chest. capable of causing invasive pneumonic lesions in the setting of reduced immunity. Such infections are a major cause of illness in these patients. occurs most frequently in workers exposed to large quantities of oily mist and in the elderly. it had been known that if the immune system was compromised by immunosuppressive drugs (given. The disease makes its appearance from 1 to 16 weeks after exposure to highdose X-rays has ceased. physical examination. Infections with fungi such as 112 . Scar tissue forms as a result of the presence of the oil.
the first symptoms of Legionnaire disease are general malaise and headache. a U. Coughing. occurred in Murcia. military veterans’ organization. in 2001. Spain. Typically.S. at a Philadelphia hotel where 182 Legionnaires contracted the disease. Legionnaire Disease Legionnaire disease is a form of pneumonia caused by the bacillus Legionella pneumophila. 113 . and occasionally some mental confusion is present. pleurisy-like pain. shortness of breath. Potable water and drainage systems are suspect. The name of the disease (and of the bacterium) is derived from a 1976 state convention of the American Legion. confirmed in more than 300 people. and abdominal distress are common. followed by high fever. but not uniformly.7 Infectious Diseases of the Respiratory System 7 Candida also occur. The diagnosis and management of these cases has become a challenging and time-consuming responsibility for respiratory specialists in locations with large numbers of AIDS cases. pneumophila in droplets into the surrounding atmosphere. It is suspected that contaminated water in central air-conditioning units can serve to disseminate L. the most common patients are elderly or debilitated individuals or persons whose immunity is suppressed by drugs or disease. the exact source of outbreaks is often difficult to determine. as is water at construction sites. The largest known outbreak of Legionnaire disease. Although it is fairly well documented that the disease is rarely spread through person-to-person contact. Although healthy individuals can contract Legionnaire disease. 29 of them fatally. often accompanied by chills. People who have cirrhosis of the liver caused by excessive ingestion of alcohol also are at higher risk of contracting the disease.
Indeed. at which time improved health and hygiene brought about a steady decline in its mortality rates. Mycobacterium tuberculosis. headache. Since the 114 . L. the bacillus spreads slowly and widely in the lungs. causing the infected person to cough up bright red blood. However. releasing large numbers of bacteria into the lungs and thus repeating the cycle of macrophage ingestion and bacterial replication. was the leading cause of death for all age groups in the Western world from that period until the early 20th century. pneumophila enters the lungs. Eventually. Treatment for Legionnaire disease is with antibiotics. pneumophila. Blood vessels also can be eroded by the advancing disease. and muscle pain. tuberculosis reached near-epidemic proportions in the rapidly urbanizing and industrializing societies of Europe and North America. Tuberculosis Tuberculosis is an infectious disease that is caused by the tubercle bacillus. the macrophage dies and bursts open. this cycle of infection can lead to severe pneumonia. and death. where cells of the immune system called macrophages immediately attempt to kill the bacteria by a process called phagocytosis.7 The Respiratory System 7 Once in the body. L. Pontiac fever. “consumption.” as it was then known. During the 18th and 19th centuries. represents a milder form of Legionella infection. coma. In some cases. pneumophila is able to evade phagocytosis and take control of the macrophage to facilitate bacterial replication. In most forms of the disease. Measurement of Legionella protein in the urine is a rapid and specific test for detecting the presence of L. an influenza-like illness characterized by fever. causing the formation of hard nodules (tubercles) or large cheeselike masses that break down the respiratory tissues and form cavities in the lungs.
antibiotic drugs have reduced the span of treatment to months instead of years. Today. The prevalence of the disease has increased in association with the HIV/AIDS epidemic. but in areas with poor hygiene standards. tuberculosis remains a major fatal disease. 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.7 Infectious Diseases of the Respiratory System 7 Tuberculosis reached near-epidemic proportions in the 18th and 19th centuries. in less-developed countries where population is dense and hygienic standards poor. it continues to be a fatal disease continually complicated by drug-resistant strains. In addition. Fox Photos/Hulton Archive/Getty Images 1940s. an estimated one out of every four deaths from tuberculosis involves an individual coinfected with HIV. the successful elimination of tuberculosis as a major threat to public health in the world has been complicated by the 115 .
are conglomerations of tubercles. and finally are sealed up in hard. sometimes involving the use of five different agents. rod-shaped bacterium that is extremely hardy.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. The bacilli are quickly sequestered in the tissues. sometimes called latent 116 . The Course of Tuberculosis The tubercle bacillus is a small. from barely visible nodules to large tuberculous masses. coughing. Individual tubercles are microscopic in size. There the bacilli become trapped in the tissues of the body. and the infected person acquires a lifelong immunity to the disease. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. and a small scar in the lung may be visible by X-ray. In this condition. In otherwise healthy children and adults. but most of the visible manifestations of tuberculosis. A skin test taken at any later time may reveal the earlier infection and the immunity. cheeselike (caseous) in appearance. A tubercle usually consists of a centre of dead cells and tissues. in which can be found many bacilli. Minute droplets ejected by sneezing. are surrounded by immune cells. Infections with these strains are often difficult to treat and require the use of combination drug therapies. nodular tubercles. 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. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells.
causing miliary tuberculosis. In the lung. the lesion consists of a collection of dead cells in which tubercle bacilli may be seen. the cough increases. From the blood the bacilli create new tissue infections elsewhere in the body. including the lymph nodes. This causes a condition known as pulmonary tuberculosis. a highly infectious stage of the disease. Eventually. and bladder. a highly fatal form if not adequately treated. An infection of the meninges that cover the brain causes tuberculous meningitis. or collection of fluid outside the lung. This lesion may erode a neighbouring bronchus or blood vessel. Tubercular lesions 117 . Fever develops. The onset of pulmonary tuberculosis is usually insidious. they can travel to almost any organ of the body. the affected person is not contagious. causing the patient to cough up blood (hemoptysis). the patient may have chest pain from pleurisy. the original tubercles break down. and immunocompromised adults (organ transplant recipients or AIDS patients. most commonly in the upper portion of one or both lungs. usually with drenching night sweats. Particularly among infants. once the bacilli enter the bloodstream. and persistent cough. before the advent of specific drugs. bones and joints. causing a pleural effusion. sometimes after periods of time that can reach 40 years or more. weight loss. intestines. this disease was always fatal.7 Infectious Diseases of the Respiratory System 7 tuberculosis. however. In some cases the infection may break into the pleural space between the lung and the chest wall. for example). and the general health of the patient deteriorates. the elderly. the primary infection may spread through the body. though most affected people now recover. an alarming symptom. These symptoms do not subside. skin. releasing viable bacilli into the bloodstream. In fact. with lack of energy. kidneys. and there may be blood in the sputum. In some cases. genital organs.
kansasii. atypical mycobacteria. marinum. aviumintracellulare). The AIDS epidemic has given prominence to a group of infectious agents known variously as nontuberculosis mycobacteria. ulcerans. a great preference for bones and joints. often resulting in a hunchback deformity. along with the systematic identification and destruction of infected cattle. is the cause of bovine tuberculosis. It shows. and M. and scarring. M. avium (or M.7 The Respiratory System 7 may spread extensively in the lung. has led to the disappearance of bovine tuberculosis in humans in many countries. or Pott disease. M. M. Tuberculosis of the spine. 118 . The amount of lung tissue available for the exchange of gases in respiration decreases. The node swells under the skin of the neck. and mycobacteria other than tuberculosis (MOTT). M. M. Other Mycobacterial Infections Another species of bacteria. where it causes destruction of tissue and eventually gross deformity. is characterized by softening and collapse of the vertebrae. where it causes caseation of the node tissue (a condition formerly known as scrofula). From the gastrointestinal tract. bovis. and this. bovis is transmitted among cattle and some wild animals through the respiratory route. however. bovis may spread into the bloodstream and reach any part of the body. and it is also excreted in milk. M. This group includes such Mycobacterium species as M. The bovine bacillus may be caught in the tonsils and may spread from there to the lymph nodes of the neck. finally eroding through the skin as a chronic discharging ulcer. causing large areas of destruction. Pasteurization of milk kills tubercle bacilli. and if untreated the patient will die from failure of ventilation and general toxemia and exhaustion. cavities. If the milk is ingested raw. bovis readily infects humans.
stained with a compound that penetrates the organism’s cell wall. it causes a local reaction. and this means treating infectious patients quickly. A vaccine. and other organs only in people whose immune systems have been weakened. however. lies in preventing exposure to infection. the sputum specimen is cultured on a special medium to determine whether the bacilli are M. tuberculosis. atypical mycobacterial illnesses are common complications of HIV infection. If bacilli are present. lymph nodes. possibly in isolation until they are noninfectious. in the urine. It has been widely used in some countries with success. is composed of specially weakened tubercle bacilli. individuals at risk 119 . known as BCG vaccine. but the prognosis is usually poor owing to the AIDS patient’s overall condition. Among AIDS patients. Diagnosis and Treatment of Tuberculosis The diagnosis of pulmonary tuberculosis depends on finding tubercle bacilli in the sputum. tuberculosis for several years. or in the cerebrospinal fluid. but they cause dangerous illnesses of the lungs.7 Infectious Diseases of the Respiratory System 7 These bacilli have long been known to infect animals and humans. in gastric washings. Injected into the skin. its use in young children in particular has helped to control infection in the developing world. The main hope of ultimate control. Treatment is attempted with various drugs. and examined under a microscope. 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 many developed countries. which confers some immunity to infection by M. The primary method used to confirm the presence of bacilli is a sputum smear. The prevention of tuberculosis depends on good hygienic and nutritional conditions and on the identification of infected patients and their early treatment.
surgery is rarely needed. As a result. In the 1940s and ’50s several antimicrobial drugs were discovered that revolutionized the treatment of patients with tuberculosis. the surviving bacilli will become resistant to several drugs. often years. such as health care workers. Historically. If a patient does not continue treatment for the required time or is treated with only one drug. If subsequent treatment is also incomplete. bacilli will become resistant and multiply. Continuous treatment may consist of once daily or twice weekly doses of isoniazid and rifampicin or isoniazid and rifapentine. such as ethambutol. with early drug treatment. rifampicin. making the patient sick again. in order to avoid the development of drug-resistant bacilli. and pyrazinamide. are regularly given a skin test (tuberculin test) to show whether they have had a primary infection with the bacillus. pyrazinamide. the treatment of tuberculosis consists of drug therapy and methods to prevent the spread of infectious bacilli. or rifapentine. Patients with strongly suspected or confirmed tuberculosis undergo an initial treatment period that lasts two months and consists of combination therapy with isoniazid. The most commonly used antituberculosis drugs are isoniazid and rifampicin (rifampin). but complete cure requires continuous treatment for another four to nine months. 120 . ethambutol. treatment of tuberculosis consisted of long periods. Today. These drugs are often used in various combinations with other agents. These drugs may be given daily or two times per week. The patient is usually made noninfectious quite quickly. 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.7 The Respiratory System 7 for tuberculosis. of bed rest and surgical removal of useless lung tissue.
In addition. amikacin. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. Although some patients consider DOT invasive. XDR TB is characterized by resistance to not only isoniazid and rifampin but also a group of bactericidal drugs known as fluoroquinolones and at least one aminoglycoside antibiotic. such as kanamycin. 121 .7 Infectious Diseases of the Respiratory System 7 Multidrug-resistant tuberculosis (MDR TB) is a form of the disease in which bacilli have become resistant to isoniazid and rifampicin. Aggressive treatment using five different drugs. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients. Instead of taking daily medication on their own. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. In 1995. MDR TB is treatable but is extremely difficult to cure. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. it has proved successful in controlling tuberculosis. in part to prevent the development and spread of MDR TB. or capreomycin. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT).
and lungs. emphysema. It is common for more than one part of the system to be involved in any particular disease process. Many noninfectious respiratory conditions are chronic and thus may ultimately result in progressive deficiency in respiratory function. trachea. diseases of the pleura. Important examples of diseases and disorders of the respiratory system include sleep apnea. and in many cases therapy may include not only the administration of medications but invasive surgery as well. palate. These conditions can be classified according to the specific anatomical regions of the respiratory tract that they affect. Conditions affecting these tissues may 122 . they are by no means rigid. and disease in one region frequently leads to involvement of other parts.CHAPTER5 DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM here exists a wide variety of noninfectious diseases and disorders of the human respiratory system. T diseases of the upper airway The nose. ranging from inherited genetic mutations to smoking to trauma. Although these divisions provide a general outline of the ways in which diseases may affect the lung. diseases of the larynx. bronchial tree. there are diseases of the upper airways. The causes of the various diseases and disorders are diverse. Thus. Treatment for this group of conditions is similarly varied. and diseases of the mediastinum and diaphragm. and nasopharynx are all susceptible to disease. and cystic fibrosis. sinuses.
which necessitates breathing through the mouth.com / Stephanie Horrocks 123 . Snoring is more common in the elderly because the loss of tone in the oropharyngeal Although snoring bears the brunt of many jokes. loud interrupted snoring can indicate sleep apnea. cancer).istockphoto. such as congenital structural abnormalities or malignant neoplastic changes (i. It is often associated with obstruction of the nasal passages.7 Diseases and Disorders of the Respiratory System 7 result from a number of different causes.e.. Such cancers are typically more common in smokers than in nonsmokers. hoarse noise produced upon the intake of breath during sleep and caused by the vibration of the soft palate and vocal cords. a potentially life-threatening condition. © www . Snoring Snoring is a rough.
meaning “without breath. and it occurs most often in obese persons. at which point the airway reopens and the person resumes breathing. Children’s snoring usually results from enlarged tonsils or adenoids. with the likelihood of OSA increasing 124 . The word apnea is derived from the Greek apnoia. which is very rare and results from failure of the central nervous system to activate breathing mechanisms. In severe cases this may occur once every minute during sleep and in turn may lead to profound sleep disruption. which involves characteristics of both obstructive and central apneas. and mixed. In addition. central. such as neck size. repetitive interruption of normal breathing can lead to a reduction in oxygen levels in the blood. the condition has a strong association with certain measures of obesity. 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. airway collapse is eventually terminated by a brief awakening. Sleep Apnea Sleep apnea is a respiratory condition characterized by pauses in breathing during sleep. Obstructive sleep apnea is most often caused by excessive fat in the neck area. or body-mass index. Thus. In obstructive sleep apnea (OSA). It is also more common in men than in women. a common and potentially lifethreatening condition that generally requires treatment. body weight.” There are three types of sleep apnea: obstructive. which is the most common form and involves the collapse of tissues of the upper airway. Loud interrupted snoring is a regular feature of sleep apnea.7 The Respiratory System 7 musculature promotes vibration of the soft palate and pharynx. In men shirt size is a useful predictor. Whatever the cause.
and it may be for this reason that patients of East Asian heritage are more likely to have sleep apnea without being overweight. Treatment typically involves continuous positive airway pressure (CPAP). worsen short-term memory. The most common symptom of OSA is sleepiness. 125 . The bed partner is likely to describe heavy snoring (OSA is exceptionally unusual without snoring) and may have observed the apneic pauses. including ischemic heart disease. The condition is also more common in patients with a set-back chin (retrognathia).5 inches). and insulin resistance. However. it is less certain that these diseases are caused by OSA. hypertension. Patients with OSA and sleepiness are at increased risk of motor vehicle accidents.7 Diseases and Disorders of the Respiratory System 7 with a collar greater than about 42 cm (16. it is more likely that they are secondary consequences of obesity and a sedentary lifestyle. which uses a mask (facial or nasal) during sleep to blow air into the upper airway. which can be resolved only by weight loss or treatment of underlying conditions. and increase irritability. Although CPAP does not treat the condition itself. though surgery is seldom recommended. Sleep disturbance may cause difficulty concentrating. with many patients describing sleep as unrefreshing. it does prevent airway collapse and thus relieves daytime sleepiness. Patients with severe OSA—those who stop breathing more often than once every two minutes—are at risk of other diseases. Other causes of the condition include medical disorders. with the resumption of breathing usually described as a gasp or a snort. the magnitude of the increased risk is the subject of some debate but is thought to be between three. such as hypothyroidism or tonsillar enlargement. Some patients with sleep apnea may be treated with a dental device to advance the lower jaw. The risk returns to normal after treatment.and sevenfold.
Finally. excessive fluid accumulates throughout the body (peripheral edema). (By some definitions. leading to respiratory acidosis. Low blood oxygen causes the small blood vessels entering the lungs to constrict. to be obese is to exceed one’s ideal weight by 20 percent or more. Individuals who have pickwickian syndrome often complain of slow thinking. diseases of the pleura The most common disease of the pleura is caused by inflammation and is referred to as pleurisy. and fatigue. is a complex of respiratory and circulatory symptoms associated with extreme obesity. drowsiness.7 The Respiratory System 7 Pickwickian Syndrome Pickwickian syndrome. The elevated pressure stresses the right ventricle of the heart. especially beneath the skin of the lower legs. Other conditions of the pleura may arise from inflammatory or neoplastic processes that lead to fluid accumulation (pleural effusion) between the two pleural layers. oxygen in the blood is also significantly reduced. also known as obesity hypoventilation syndrome. ultimately causing right heart failure. In more severe instances. in the space known as the pleural cavity. levels of carbon dioxide in the blood increase. The pleural membranes of the 126 . who showed some of the same traits.) This condition often occurs in association with sleep apnea. Because of inadequate removal of carbon dioxide by the lungs. thus increasing pressure in the vessels that supply the lungs. an extremely obese person would exceed the optimum weight by a much larger percentage. The name originates from the fat boy depicted in Charles Dickens’s The Pickwick Papers. In pickwickian syndrome the rate of breathing is chronically decreased below the normal level.
a cancer of the pleura. sometimes in quantities sufficient to compress the underlying lung and cause shortness of breath. Mesothelioma. or hydrothorax. Pleurisy may be characterized as dry or wet. In dry pleurisy. fluid evacuation. Treatment of pleurisy includes pain relief.7 Diseases and Disorders of the Respiratory System 7 lungs are also vulnerable to perforation and spontaneous rupture. a partial or occasionally complete collapse of the lung. is an inflammation of the pleura. including tissues of the neck and head. pleurisy can be very painful. Pleural Effusion and Thoracic Empyema Pleural effusion. is an accumulation of watery fluid in the pleural cavity. and treatment of the underlying disease. also called pleuritis. and the inflamed surfaces of the pleura produce an abnormal sound called a pleural friction rub when they rub against one another during respiration. The cancerous cells of the pleura can eventually metastasize and invade nearby and distant tissues. Pleurisy is commonly caused by infection in the underlying lung and. little or no abnormal fluid accumulates in the pleural cavity. This rubbing may be felt by the affected person or heard through a stethoscope applied to the surface of the chest. Because the pleura is well supplied with nerves. In wet pleurisy. This causes spontaneous pneumothorax. rarely. fluids produced by the inflamed tissues accumulate within the pleural cavity. There are many causes of 127 . by diffuse inflammatory conditions such as lupus erythematosus. Pleurisy Pleurisy. may occur many years after inhalation of asbestos fibres. the membranes that line the thoracic cavity and fold in to cover the lungs. enabling air to enter the pleural cavity.
and fluid that seeps from the lungs places additional stress on the dysfunctioning heart. including pneumonia. When the bronchial tree is involved in the infection..e. and weight loss. This condition is often the result of a microbial. Examples of sclerosing agents that cause an inflammatory reaction of the pleural surfaces include talc. a tube is inserted through the chest wall into the pleural space to drain the fluid. The presence of both air and pus inside the pleural cavity is known as pneumothorax. shortness of breath. coughing.7 The Respiratory System 7 pleural effusion. doxycycline. tissue adhesions obliterate the pleural space. such as malignant disease of the pleura (i. Treatment is directed at drainage of small amounts of pus through 128 . tuberculosis. The most common cause is lung inflammation (pneumonia) resulting in the spread of infection from the lung to the bordering pleural membrane. Under certain conditions. Thoracic empyema may be characterized by fever. thereby preventing the accumulation of more fluid. infection within the pleural cavity. Pleural effusion often develops as a result of chronic heart failure because the heart cannot pump fluid away from the lungs. It may also be caused by a lung abscess or some forms of tuberculosis. air may get into the pleural cavity. and the presence of fluid as ascertained by a chest X-ray. As the inflammation heals. and bleomycin. or pyothorax. pleural effusion can be treated by introducing an irritating substance called a sclerosing agent into the pleural space in order to stimulate an inflammatory reaction of the pleural surfaces. If symptoms of pleural effusion develop. usually bacterial. The accumulation of pus in the pleural cavity is known as thoracic empyema. Large pleural effusions can cause disabling shortness of breath. and the spread of a malignant tumour from a distant site to the pleural surface. mesothelioma).
lung infection. 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. air and pressure accumulate within the chest. In contrast to traumatic pneumothorax and spontaneous pneumothorax. When the lung on the affected side of the chest collapses. with each breath the patient inhales. The symptoms of spontaneous pneumothorax are a sharp pain in one side of the chest and shortness of breath. gunshot) or other injuries to the chest wall. spontaneous pneumothorax. Tension pneumothorax is a life-threatening condition that can occur as a result of trauma. after which air is sucked through the opening and into the pleural sac. There are three major types of pneumothorax: traumatic pneumothorax. such as high-pressure mechanical ventilation. or medical procedures. and tension pneumothorax. blood 129 . in tension pneumothorax air that becomes trapped in the pleural space cannot escape. Video-assisted thoracic surgery or open-chest surgery is sometimes needed to eviscerate thick or compartmentalized pus from the pleural space. or thoracoscopy (closed-lung biopsy). the heart. As a result.7 Diseases and Disorders of the Respiratory System 7 a needle or larger amounts through a drainage tube. which may then collapse. causing it to expand and thus compress the underlying lung. Traumatic pneumothorax is the accumulation of air caused by penetrating chest wounds (knife stabbing. Pneumothorax Pneumothorax is a condition in which air accumulates in the pleural space. Antibiotics are used to treat the underlying infection. chest compression during cardiopulmonary resuscitation (CPR).
The bronchi become chronically infected. This leads to decreases in blood pressure. This procedure allows air to escape from the chest cavity. In some cases. occasionally. and breathing that in turn may lead to shock and death. In fact. a catheter connected to a vacuum system is required to re-expand the lung. The disease may also develop as a consequence of airway obstruction or of undetected (and 130 . Whereas several diseases of the bronchi and lungs. While small pneumothoraxes may resolve spontaneously. many of these conditions are associated with irreversible lung damage. It consists of a dilatation of major bronchi. clubbing (swelling of the fingertips and. Bronchiectasis Bronchiectasis is believed to usually begin in childhood. others may require surgery to prevent recurrences. others (such as pulmonary emphysema and chronic obstructive pulmonary disease) occur in adulthood and are frequently associated with excessive exposure to tobacco smoke. diseases of the bronchi and lungs Diseases of the bronchi and lungs are often associated with significant impairments in respiration. In some cases. which enables the lung to reexpand. and airways are pushed to the centre of the chest. including bronchiectasis and cystic fibrosis. consciousness. may be present in childhood. Most pneumothoraxes can be treated by inserting a tube through the chest wall. thereby compressing the other lung. of the toes) may occur. and excess sputum production and episodes of chest infection are common. possibly after a severe attack of pneumonia.7 The Respiratory System 7 vessels.
and postural drainage and percussion to loosen mucus in the lungs so it can be expelled through coughing. now reach adult life.7 Diseases and Disorders of the Respiratory System 7 therefore untreated) aspiration into the airway of small foreign bodies. Management of the condition includes antibiotics to fight lung infections. have helped control pulmonary infections and have markedly improved survival in affected persons. such as parts of plastic toys. many of whom. But the striking increase in mortality from chronic bronchitis and emphysema that occurred after World War II in all Western countries indicated that the long-term consequences of chronic bronchitis could be serious. due to an increase in size and number of mucous glands lining the large airways. in addition to others. who would formerly have died in childhood. Chronic Bronchitis The chronic cough and sputum production of chronic bronchitis were once dismissed as nothing more than “smoker’s cough. of which the most important is the familial disease cystic fibrosis. This common condition is characteristically produced by cigarette smoking. chronic bronchitis is sometimes caused by prolonged inhalation of environmental irritants. After about 15 years of smoking. For example. particularly in areas of uncontrolled coal burning. significant quantities of mucus are coughed up in the morning. These therapies. The increase in mucous cells and the development of chronic bronchitis may be enhanced by breathing polluted air. or of organic substances such as hay dust. enzyme therapy to thin the mucus. medications to dilate the airways and to relieve pain.” without serious implications. Bronchiectasis may also develop as a consequence of inherited conditions. In some countries chronic bronchitis is caused by daily 131 .
For current smokers the most important treatment of chronic bronchitis is the cessation of smoking. Smoking-related chronic bronchitis often occurs in association with emphysema. but they must be used sparingly because they can be addictive and because expectoration is necessary.7 The Respiratory System 7 inhalation of wood smoke from improperly ventilated cooking stoves. Unfortunately. as measured by the velocity of a single forced expiration. is severely compromised. treatment is mainly symptomatic. in a cigarette smoker. It is not clear what determines the severity of these changes. the coexistence of these two conditions is known as chronic obstructive pulmonary disease. Because the damage to the bronchial tree is largely irreversible. Some people can smoke for decades without evidence of significant airway changes. causing a fall in arterial oxygen tension and a rise in carbon dioxide tension. All these changes together. can lead to disturbances in the distribution of ventilation and perfusion in the lung. drugs to suppress paroxysmal coughing may be necessary. whereas others may experience severe respiratory compromise after 15 years or less of exposure. By the time this occurs. the ventilatory ability of the patient. The mucus-producing cough will subside within weeks or months and may resolve altogether. Of primary importance is 132 . though the rate of progression generally slows. Changes in smaller bronchioles lead to obliteration and inflammation around their walls. if severe enough. Occasionally. The changes are not confined to large airways. ventilatory ability has usually been declining rapidly for some years. consisting of expectorants and bronchodilators. narrowing of the bronchi and obstruction of airflow may continue to progress even after smoking ceases. though these produce the dominant symptom of chronic sputum production.
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
which is replaced by holes characteristic of emphysema. antibiotics. COPD is distinguished pathologically by the destruction of lung tissue. which causes increased lung volume and manifests as breathlessness. Exacerbations are triggered by infection. indicate a poor prognosis. Other early symptoms of the condition include a “smoker’s cough” and daily sputum production.000 people in the United Kingdom and roughly 119. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. particularly lung cancer. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. either bacterial or viral. are not always required. and by a tendency for excessive mucus production in the airway. which gives rise to symptoms of bronchitis. particularly if severe enough to warrant hospital admission. It is a common disease. tobacco-related condition. 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. air pollution. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). Sources of noxious particles that can cause COPD include tobacco smoke. Frequent exacerbations. and each year about 30. and the burning of certain fuels in poorly ventilated areas. which 137 . which work against bacteria. Although primarily a lung disease.000 people in the United States die from COPD. Therefore. including muscle weakness and osteoporosis. In rare cases COPD has been associated with a genetic defect that results in deficiency of alpha-1 antitrypsin.
high blood pressure.. Lung Congestion Lung congestion is characterized by distention of blood vessels in the lungs and filling of the alveoli with blood as a result of an infection. which leads to further difficulties in mobility. Specialized centres can offer treatments for patients with advanced disease.e. inability of the heart to function adequately). and the prescription of oxygen for patients who smoke remains controversial because of the risk for explosion. especially for patients with frequent exacerbations. bronchodilators). since they need to use it for 16 hours each day to derive benefit. Inhaled corticosteroids are commonly prescribed. lung transplantation and lung-volume reduction).e.. In addition. the prescription of home oxygen can reduce hospital admission and extend survival but does not alter the progression of lung disease.e. or cardiac insufficiencies (i. oxygen is extremely flammable. Active congestion of the lungs is caused by 138 . In COPD patients with low blood–oxygen levels. This should be followed by a community/home maintenance program or by repeat courses every two years.to eight-week course of pulmonary rehabilitation often benefits patients who have symptoms despite inhaler therapy. A six. Treatments used in the early stages of disease include vaccination against influenza and pneumococcal pneumonia and administration of drugs that widen the airways (i. Short courses (typically five days) of oral corticosteroids are given for exacerbations but generally are not used in the routine management of COPD..7 The Respiratory System 7 can be accomplished in most cases by cessation of smoking. including noninvasive ventilation and surgical options (i. Some COPD patients do not find oxygen attractive.
In 139 . and they begin to distend. and the precipitating causes may somewhat differ. 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. Mitral stenosis. and blood escapes through the capillary wall into the alveoli. and particles. when the remaining functioning tissue becomes infected. The major complication arises in mild cases of pneumonia. The blood pressure becomes high in the alveolar capillaries. or to relaxation of the blood capillaries followed by blood seepage.7 Diseases and Disorders of the Respiratory System 7 infective agents or irritating gases. rather than whole blood. Passive congestion caused by relaxation of the blood vessels occurs in bedridden patients with weak heart action. although there is usually enough unaffected lung tissue for respiration. Blood accumulates in the lower part of the lungs. Inflammatory edema results from influenza or bacterial pneumonia. flooding them. there is a bloody discharge. caused by a cardiac disorder. The alveolar walls and the capillaries in them become distended with blood. Pulmonary edema is much the same as congestion except that the substance in the alveoli is the watery plasma of blood. Passive congestion is due either to high blood pressure in the capillaries. and the skin takes on a bluish tint as the disease progresses. Eventually the pressure becomes too great. causes chronic passive congestion. liquids. narrowing of the valve between the upper and lower chambers in the left side of the heart. The walls of the alveoli also thicken and gas exchange is greatly impaired. The affected person shows difficulty in breathing. Iron pigment from the blood that congests the alveoli spreads throughout the lung tissue and causes deterioration of tissue and formation of scar tissue.
Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6241) 140 . Dr.7 The Respiratory System 7 X-ray showing lung congestion caused by congestive heart failure.
7 Diseases and Disorders of the Respiratory System 7 mechanical edema the capillary permeability is broken down by the same type of heart disorders and irritants as in congestion. After an operation. enlarged. and heavy. their lungs show areas in which the alveoli. It may take only one or two hours for two to three quarts of liquid to accumulate. the person may actually drown in the lung secretions. after reinflation of a collapsed lung. Excessive irradiation and severe allergic reactions may also produce this disorder. The term atelectasis can also be used to describe the collapse of a previously inflated lung. either partially or fully. and. Adhesive atelectasis is seen in premature infants who are unable to spontaneously breathe and in some infants after only a few days of developing breathing difficulties. Acute cases can be fatal in 10 to 20 minutes. compressive. for unknown reasons. These infants usually suffer from a disorder called respiratory distress syndrome. with deep gurgling rattles in the throat. the blood pressure rises and edema ensues. because of specific respiratory disorders. This is typically caused by a failure to develop surface-active material 141 . A person with pulmonary edema experiences difficulty in breathing. are not expanded with air. The lungs become pale. The term is derived from the Greek words atele s and ektasis. if too great a volume of intravenous fluids is given. wet. in which the surface tension inside the alveolus is altered so that the alveoli are perpetually collapsed. and obstructive. It can occur. There are three major types of atelectasis: adhesive. Atelectasis Atelectasis is characterized primarily by the absence of air in the lungs. because he or she is too weak to clear the fluids. or air sacs. literally meaning “incomplete expansion” ¯ in reference to the lungs. The person’s skin turns blue.
Thomas Hooten/Centers for Disease Control and Prevention (CDC) (Image Number: 6242) 142 . Dr.7 The Respiratory System 7 X-ray showing changes in the right upper pulmonary lung field that are characteristic of atelectasis.
the respiratory tissue is replaced by fibrous scar tissue. Generally. Mucous plugs can result that cause atelectasis. The air passageways in the lungs normally secrete a mucous substance to trap dust. Local pressure can result from tumour growths. the anesthetic stimulates an increase in bronchial secretions. and the muscles beneath the lungs may be weakened.7 Diseases and Disorders of the Respiratory System 7 (surfactant) in the lungs. soot. which frequently enter with inhaled air. Treatment for infants with this syndrome includes replacement therapy with surfactant. It may also occur as a complication of abdominal surgery. After abdominal surgery. Treatment for obstructive and compressive 143 . When a person undergoes surgery. and consolidation of the lungs into a smaller mass. Compressive atelectasis is caused by an external pressure on the lungs that drives the air out. which manifests as a bluish tint to the skin. Other causes of obstruction include tumours or infection. or elevation of the diaphragm. and bacterial cells. displacement of the heart toward the affected side. they can be pushed out of the bronchi by coughing or strong exhalation of air. causing air trapped in the alveoli to be slowly absorbed by the blood. absence of respiratory movement on the side involved. The ducts and bronchi leading to the alveoli are squeezed together by the pressure upon them. The symptoms in extreme atelectasis include low blood oxygen content. Obstructive atelectasis may be caused by foreign objects lodged in one of the major bronchial passageways. an enlarged heart. If a lung remains collapsed for a long period. and respiratory function cannot be restored. if these secretions become too abundant. Collapse is complete if the force is uniform or is partial when the force is localized. the breathing generally becomes more shallow because of the sharp pain induced by the breathing movements.
144 . however. those extending to the outer surface cause fluids and blood to seep into the space between the lungs and the pleural sac. The sac distends with the excess fluid and there may be difficulty in inflating the lungs. Ordinarily. near the muscular diaphragm that separates the chest cavity from the abdomen. or air bubbles in the bloodstream (both of these are instances of embolism). when the lungs are healthy. or the blockage may be by a clot that has formed in the blood vessel itself and has remained at the point where it was formed (such a clot is called a thrombus). or inadequately supplied with air. or it may be lower. such blockages fail to cause death of tissue because the blood finds its way by alternative routes. Lung Infarction Lung infarction is the death of one or more sections of lung tissue due to deprivation of an adequate blood supply. The obstruction may be a blood clot that has formed in a diseased heart and has traveled in the bloodstream to the lungs. Because neither the lung tissue nor the pleural sac surrounding the lungs has sensory endings. shoulders. Pain is most severe on inhalation.7 The Respiratory System 7 atelectasis is directed toward removal of any obstruction or compressive forces. If the lung is congested. The cessation or lessening of blood flow results ordinarily from an obstruction in a blood vessel that serves the lung. One explanation for the pain is that it is from tension on the sensitive nerve endings in the membrane lining the chest. and neck. The pain may be localized around the rib cage. infarcts that occur deep inside the lungs produce no pain. lung infarctions can follow blockage of a blood vessel. The section of dead tissue is called an infarct. infected. When pain is present it indicates pleural involvement.
when both 145 . increased heartbeat. Infarcts that do not heal within two or three days generally take two to three weeks to heal.e. The disease has no manifestations in heterozygotes (i. The disorder was long known to be recessive (i... pleural rubbing.7 Diseases and Disorders of the Respiratory System 7 The symptoms of infarcts are generally spitting up of blood. However. those individuals who have one normal copy and one defective copy of the particular gene involved). and a dull sound heard when the chest is tapped. However. more than half of all victims of cystic fibrosis survived into adulthood owing to aggressive therapeutic measures. the chief symptom of which is the production of a thick. Cystic Fibrosis Cystic fibrosis. The blood shows an increase in number of white blood cells and sedimentation rate (clumping of red blood cells). is an inherited metabolic disorder. also known as mucoviscidosis. only persons inheriting a defective gene from both parents will manifest the disease). Cystic fibrosis is an inherited disorder mainly affecting people of European ancestry.000 live births in these populations and is particularly concentrated in people of northwestern European descent. by the mid-1980s.000 live births) and is very rare in people of Asian ancestry. Cystic fibrosis was not recognized as a separate disease until 1938 and was then classified as a childhood disease because mortality among afflicted infants and children was high.e. It is much less common among people of African ancestry (about 1 per 17. diminished breath sounds. The dead tissue is replaced by scar tissue. moderate difficulty in breathing. coughing. It is estimated to occur in 1 per 2. sticky mucus that clogs the respiratory tract and the gastrointestinal tract. fever.
which is the most common cause of death of persons with cystic fibrosis. These functions are critical for maintaining and adjusting the fluidity of mucous secretions. This results in chronic respiratory infections. Bulky. recurrent pneumonia. In 1989 the defective gene responsible for cystic fibrosis was isolated. and the progressive loss of lung function are the major manifestations of lung disease. sticky mucus accumulates in the lungs. The resulting maldigestion and malabsorption of food can cause affected individuals to become malnourished despite an adequate diet. The thick. often with Staphylococcus aureus or Pseudomonas aeruginosa. plugging the bronchi and making breathing difficult. on the basis of chance. foul-smelling stools are often the first signs of cystic fibrosis. Cystic fibrosis affects the functioning of the body’s exocrine glands (e. As a result. chloride and sodium ions accumulate within cells. In the digestive system. The gene. lies in the middle of chromosome 7 and encodes a protein of the same name. or CFTR.g. greasy. Chronic cough..7 The Respiratory System 7 parents are heterozygous. About 10 146 . called cystic fibrosis transmembrane conductance regulator. the abnormally thick mucous secretions interfere with the passage of digestive enzymes and thus block the body’s absorption of essential nutrients. 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. one out of four of their offspring will have the disease. the CFTR protein transports chloride across cell membranes and regulates other channels. thereby drawing fluid into the cells and causing dehydration of the mucus that normally coats these surfaces. the mucus-secreting and sweat glands) in the respiratory and digestive systems. they may expect that. designated CFTR. Within the cells of the lungs and gut.
a recombinant form of the enzyme deoxyribonuclease. Mutations associated with cystic fibrosis can be detected in screening tests. The high salt content in perspiration is the basis for the “sweat test.” which is the definitive diagnostic test for the presence of cystic fibrosis. protein. These agents may be administered by means of an inhaler or a nebulizer. In severe cases. in order to fight lung infections.7 Diseases and Disorders of the Respiratory System 7 percent of infants with cystic fibrosis have intestinal obstruction at birth due to very thick secretions. The anti-inflammatory agent ibuprofen has been shown to slow the deterioration of lung tissue in some cystic fibrosis patients. mutations in the CFTR gene are associated with degeneration of the ductus deferens and sterility in adult males who have cystic fibrosis. Vigorous physical therapy on a daily basis is used to loosen and drain the mucous secretions that accumulate in the lungs. lung transplantation may be considered. Many patients with cystic fibrosis regularly take antibiotics. as well as in the identification of newborns who may be at risk for the disorder. are given to thin mucus. In addition. The treatment of cystic fibrosis includes the intake of pancreatic enzyme supplements and a diet high in calories. making it easier for patients to breathe. These tests are effective in the identification of adult carriers (heterozygotes). facilitating its clearance from the lungs through coughing. which is powered by a compressor that sprays aerosolized drug into the airways. 147 . In addition. Medications such as dornase alfa. Cystic fibrosis causes the sweat glands to produce sweat that has an abnormally high salt content. bronchodilators can be used to relax the smooth muscles that line the airways and cause airway constriction. sometimes in aerosolized form. who may pass a mutation on to their offspring. and fat.
7 The Respiratory System 7 Among the most promising treatments under investigation for cystic fibrosis is gene therapy. Gene therapy first emerged as a potential form of treatment in 1990. This success led to the first clinical trial of gene therapy for cystic fibrosis in 1993. which can bind to a type of receptor expressed in high numbers on the surfaces of lung cells. including lung inflammation and signs of viral infection. However. has proved particularly effective in laboratory studies using human lung tissue. 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. which subsequently incorporated the normal genes into their DNA. This first trial initially appeared to be successful. since increased expression of the CFTR protein was observed shortly after treatment. and adenovirus associated virus. gene therapy for cystic fibrosis has undergone significant refinement. As a result. 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 latter. and the outcomes of clinical trials are marked by steady improvement. These vectors were then transfected into the cultured cells. However. Delivery systems under investigation include cationic polymer vectors. cationic liposomes. The researchers used recombinant DNA technology to generate viral vectors containing normal copies of the CFTR gene. when researchers successfully restored CFTR chloride channel function in cultured lung and airway epithelial cells that carried CFTR mutations. the patients experienced severe side effects. 148 . the development of an effective gene delivery system has become a major focus of cystic fibrosis gene therapy. Since the 1990s.
the lung is commonly involved.7 Diseases and Disorders of the Respiratory System 7 Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis is also known as cryptogenic fibrosing alveolitis. pulmonary function testing shows a reduction in lung volume. In addition. A dry cough is common as well. Sharp crackling sounds. Other common changes are enlargement of the lymph 149 . there is no effective treatment. in different organs. Sarcoidosis and Eosinophilic Granuloma Sarcoidosis is a disease of unknown cause characterized by the development of small aggregations of cells. however. some people live 10 years or longer. Lung biopsies confirm the diagnosis by showing fibrosis with a lack of inflammation. Computerized tomography (CT) imaging shows fibrosis and cysts that characteristically form in a rim around the lower outer portions of both lungs.” are heard through a stethoscope applied to the back in the area of the lungs. or granulomas. called rales or “Velcro crackles. The average duration of survival from diagnosis is four to six years. The disease most commonly manifests between ages 50 and 70. Some individuals have clubbed fingertips and toes. This is a generally fatal lung disease of unknown cause that is characterized by progressive fibrosis of the alveolar walls. with insidious onset of shortness of breath on exertion. Some individuals may benefit from single or double lung transplantation. The disease causes progressive shortness of breath with exercise and ultimately produces breathlessness at rest. Hypoxemia (decreased levels of oxygen in the blood) initially occurs with exercise and later at rest and can be severe. Aside from administration of supplemental oxygen.
Pulmonary Alveolar Proteinosis Pulmonary alveolar proteinosis is a respiratory disorder caused by the filling of large groups of alveoli with excessive amounts of surfactant. Although its cause is unknown. inflammation in the eye. a subgroup of immune cells.7 The Respiratory System 7 glands at the root of the lung.” leaving the lung with some permanent cystic changes. Eosinophilic granuloma is a lung condition that may spontaneously “burn out. the incidence is greatly increased in cigarette smokers. The disease usually remits without treatment within a year or so. also known as histiocytosis X. Eosinophilic granuloma. and liver dysfunction. Evidence of granulomas in the lung may be visible. Occasionally. nerve sheaths are inflamed. In most cases the disease is first detected on chest radiographs. When too much surfactant is released from the alveolar cells. minute structures in the lungs in which the exchange of respiratory gases occurs. or when the lung fails to remove the 150 . the surface of which is generally covered by a thin film of surfactant material secreted from the alveolar cells. leading finally to lung fibrosis and respiratory failure. It causes lesions in lung tissue and sometimes also in bone tissue. is a disease associated with the excess production of histiocytes. but some changes in blood calcium levels occur in a small percentage of cases. The gas molecules must pass through a cellular wall. but in a small proportion of cases it progresses. skin changes. leading to signs of involvement in the affected area. a complex mixture of protein and lipid (fat) molecules. The granulomatous inflammation in sarcoidosis can be controlled by long-term administration of a corticosteroid such as prednisone. but often there is little interference with lung function. The alveoli are air sacs. The kidney is not commonly involved.
if treated. The disease manifests itself in laboured breathing at rest or shortness of breath with exertion. an indication that blood is not being adequately oxygenated or rid of carbon dioxide. The fluids drawn back out of the lungs have been found to have a high content of fat. Pulmonary hemorrhage also occurs as part of a condition 151 . Wegener granulomatosis. but subsequent treatments are often necessary. it is sometimes fatal. Immunologic Conditions of the Lung The lung is often affected by generalized diseases of the blood vessels. Treatment involves removal of the material by a rinsing out of the lungs (lavage). There may also be general fatigue and weight loss. One lung at a time is rinsed with a saltwater solution introduced through the windpipe.7 Diseases and Disorders of the Respiratory System 7 surfactant. The skin becomes tinged with blue in the most serious cases. and spontaneous improvement has been known to occur. The disease can exist without causing symptoms for considerable periods. and it is often accompanied by chest pain and a dry cough. Sometimes the lesions totally clear up after one procedure. The precipitating cause of the disease is unknown. is an important cause of pulmonary blood vessel inflammation. The condition has been successfully treated by exchange blood transfusion. an acute inflammatory disease of the blood vessels believed to be of immunologic origin. Acute hemorrhagic pneumonitis occurring in the lung in association with changes in the kidney is known as Goodpasture syndrome. Persons affected are usually between ages 20 and 50. but rarely so. gas exchange is greatly hindered and the symptoms of alveolar proteinosis occur. X-rays most frequently show evidence of excess fluids in the lungs. but its cause is not fully understood.
by the use of pulmonary function tests. which results in the accumulation of the iron-containing substance hemosiderin in the lung tissues. Lung Cancer Lung cancer is a disease characterized by uncontrolled growth of cells in the lungs. Lung cancer was first described by doctors in the mid-19th century. The lung may also be involved in a variety of ways in the disease known as systemic lupus erythematosus. but by the end of the century it was the leading cause of cancer-related death among men in more than 25 developed countries. In women. lung cancer is the second leading cause of death from cancer globally. and especially by improvement in thoracic surgical techniques and anesthesia that have made lung biopsy much less dangerous than it formerly was. it has surpassed breast cancer. following breast cancer. The common condition of rheumatoid arthritis may be associated with scattered zones of interstitial fibrosis in the lung or with solitary isolated fibrotic lesions. 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. and the lung parenchyma may be involved.7 The Respiratory System 7 known as pulmonary hemosiderosis. lung cancer emerged as the leading cause of cancer deaths worldwide. These conditions have only recently been recognized and differentiated. In the United States. a slowly obliterative disease of small airways (bronchiolitis) occurs. leading finally to respiratory failure. Pleural effusions may occur. 152 .3 million deaths each year. resulting in an estimated 1. More rarely. which is also believed to have an immunologic basis. In the early 20th century it was considered relatively rare. however. accurate diagnosis has been much improved by refinements in radiological methods.
but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. Of the two basic forms. visible lumps. The most common symptoms include shortness of breath. secondhand smoke accounts for an estimated 3. jaundice. and susceptibility to lower respiratory infections.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. The risk is also greater for those who started smoking at a young age. Other risk factors include exposure to radon gas and asbestos. Uranium and pitchblende miners. In countries with a prolonged history of cigarette smoking. and roofers. unexplained weight loss. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. In cases where the cancer has spread beyond the lungs. chest pain. welders. Heavy smokers have a greater likelihood of developing the disease than do light smokers. as do some workers in hydrocarbon-related processing.400 deaths from lung cancer in nonsmoking adults in the United States each year. the tumour’s type and degree of invasiveness are determined. or bone pain may occur. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. Types of Lung Cancer Once diagnosed. such as coal processors. and workers exposed to halogenated ethers also have an increased incidence. a persistent cough or wheeze. According to the American Cancer Society. tar refiners. Tumours can begin anywhere in the lung. bloody sputum. small-cell 153 . chromium and nickel refiners. between 80 and 90 percent of all cases are caused by smoking. Lung cancer is rarely caused directly by inherited mutations.
7 The Respiratory System 7 carcinoma accounts for 20 to 25 percent of all cases and non-small-cell carcinoma is responsible for the remainder. 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. Diagnosis. also called oat-cell carcinoma. pleura. also called epidermoid carcinomas. About 10 percent of all lung cancers are large-cell carcinomas. oval. Because it tends to spread quickly before symptoms become apparent. Cancer cells may be detected in sputum. and it often develops in the larger bronchi of the central portion of the lungs. the survival rate is very low. Large-cell carcinomas can begin in any part of the lung and tend to grow very quickly. SCLC is the most aggressive type of lung cancer. adenocarcinoma. and both lungs or metastasis to other organs. is rarely found in people who have never smoked. and they form structures that resemble glands and are sometimes hollow. It is characterized by cells that are small and round. or shaped like oat grains. but it is the most common type of lung cancer in the United States. Treatment. Tumours often originate in the smaller. and Prevention Lung cancers are often discovered during examinations for other conditions. peripheral bronchi. Adenocarcinoma accounts for some 25 to 30 percent of cases worldwide. 154 . Squamous cell carcinoma tends to remain localized longer than other types and thus is generally more responsive to treatment. Non-SCLCs consist primarily of three types of tumour: squamous cell carcinoma. This tumour is characterized by flat. Cells of adenocarcinoma are cube. Some 25 to 30 percent of primary lung cancers are squamous cell carcinomas. Symptoms at the time of diagnosis often reflect invasion of the lymph nodes. scalelike cells. Small-cell carcinoma (SCLC). and large-cell carcinoma.or column-shaped.
Lung surgery is serious and can lead to complications such as pneumonia or bleeding. The type of treatment an individual patient receives may also be based on the results of genetic screening. treatments for lung cancer include surgery. abnormal fluctuations in the serum levels of parathormone or the presence in the blood of a protein called cytokeratin 19 fragment or of substances known as carcinogenic antigens may be indicative of malignant lung disease. lung cancer has a poorer prognosis than many other cancers. and radiation. which can identify mutations that render some lung cancers susceptible to specific drugs. Although removal of an entire lung does not prohibit otherwise healthy people from ultimately resuming normal activity. computed tomography (CT) scans. positron emission tomography (PET) scans. Noninvasive methods include X-rays. Even when it is detected early.7 Diseases and Disorders of the Respiratory System 7 a needle biopsy may be used to remove a sample of lung tissue for analysis. Surgery involves the removal of a cancerous segment (segmentectomy). and the type of cancer. or the large airways of the lungs (bronchi) can be viewed directly with a bronchoscope for signs of cancer. There are also several blood tests that may be used to detect proteins and other substances known to be associated with lung cancer. and magnetic resonance imaging (MRI). Radiation may be used alone or in conjunction with surgery—either before surgery to shrink tumours or 155 . As with most cancers. For this reason. Most cases are usually diagnosed well after the disease has spread (metastasized) from its original site. chemotherapy. or the entire lung (pneumonectomy). the five-year survival rate is about 50 percent. The choice of treatment depends on the patient’s general health. the stage or extent of the disease. the already poor condition of many patients’ lungs results in long-term difficulty in breathing after surgery. For example. a lobe of the lung (lobectomy).
diarrhea. noninvasive cysts of different kinds are also found in the mediastinum. Chemotherapy uses chemicals to destroy cancerous cells. and other airborne carcinogens also lowers risk. Early studies in small subsets of patients have demonstrated that microwave ablation can shrink and possibly even eliminate some lung tumours. Side effects include vomiting. An experimental technology that has shown promise in the treatment of lung cancer is microwave ablation. Enlargement of lymph glands in this region is common. Smokers who quit also reduce their risk significantly. or additional damage to the lungs. asbestos. causing side effects that are similar to radiation therapy. Primary tumours of mediastinal structures may arise from the thymus gland or the lower part of the thyroid gland. diseases of the MediastinuM and diaphragM The mediastinum comprises the fibrous membrane in the centre of the thoracic cavity. Testing for radon gas and avoiding exposure to coal products. particularly in the presence of lung tumours or as part of a generalized enlargement of lymphatic tissue in disease. The probability of developing lung cancer can be greatly reduced by avoiding smoking. Mediastinal emphysema occurs when a pocket of air forms within the mediastinum and thus surrounds the 156 . Radiation treatment may be administered as external beams or surgically implanted radioactive pellets (brachytherapy). which relies on heat derived from microwave energy to kill cancer cells. fatigue. but these chemicals also attack normal cells to varying degrees.7 The Respiratory System 7 following surgery to destroy small amounts of cancerous tissue. together with the many important structures situated within it.
where accumulating air can cause sufficient pressure to impair normal heart expansion and blood circulation. While the diver remains deeply submerged. there is no difficulty. When the alveoli of the lungs rupture because of traumatic injury or lung disease. 157 . the extra gas pressure is relieved by exhaling. Air trapped in the mediastinum expands as the diver continues to rise. Mediastinal emphysema is one of the maladies that can afflict underwater divers who breathe compressed air. This area contains the heart. rises too rapidly. and the trachea. the lungs become overinflated and rupture. or has respiratory obstructions such as cysts. the expanding air may compress the respiratory passageways. and collapse blood vessels vital to circulation. As a diver descends. or scar tissue. This usually occurs as a result of lung rupture. or they can travel through the lung tissue to other areas of the body. The air the diver breathes is more dense and concentrated than the air breathed on the surface. Air bubbles can then enter the veins and capillaries of the circulatory system directly. In mediastinal emphysema the air bubbles usually pass along the outside of blood vessels and the bronchi until they reach the mediastinal cavity. The pressure may cause intense pain beneath the rib cage and in the shoulders. main bronchi. causing an air embolism. the released air seeks an area of escape. mucus plugs. the external pressure decreases. however.7 Diseases and Disorders of the Respiratory System 7 heart and central blood vessels. If the diver breathes normally or exhales as he or she ascends at a moderate rate. the external pressure upon his or her body increases. If the diver holds his or her breath. which do not permit sufficient release of air. when he or she begins to ascend again. major blood vessels. One pathway that the air can follow is through the lung tissue into the mediastinum. and the lungs begin to expand because the air inside has less pressure to contain it. making breathing difficult.
bilateral diaphragmatic paralysis can lead to a severe reduction in vital capacity. For example. especially when the subject is recumbent (lying down).7 The Respiratory System 7 The symptoms of mediastinal emphysema may range from pain under the breastbone. If there is respiratory or circulatory distress. Diseases and disorders that affect the diaphragm can cause fundamental changes in respiratory function. shock. 158 . diaphragmatic fatigue may limit the exercise capability of affected persons. Paralysis of the diaphragm on one side is more common and better tolerated than bilateral paralysis. or it may be removed by inserting a long hypodermic needle into the mediastinum to draw off the air. In many cases the cause of the paralysis cannot be determined. In some persons the diaphragm may be incompletely formed at birth. and cyanosis (blue colouring of the skin). respiratory failure. this can lead to herniation of the abdominal viscera through the diaphragm. as occurs in emphysema. The function of the diaphragm may be compromised when the lung is highly overinflated. the air will be absorbed by the body. 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. although some shortness of breath on exertion is often present. and shallow breathing to unconsciousness.
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. Respiratory function can be severely compromised by a variety of other conditions. such as asbestos and coal dust. affected persons are highly sensitive to substances such as dust or pollen. however. hence. such as respiratory distress syndrome. exposure to harmful irritants. traumatic conditions. causes respiratory disease in otherwise healthy workers. A allergic lung diseases There are at least three reasons why the lungs are particularly liable to be involved in allergic responses. In occupational disease. and drowning are other examples of acute conditions that can result in respiratory failure. Carbon monoxide poisoning. For example. In some cases of occupational exposure. altitude sickness. and. reducing exposure to the irritant relieves the symptoms of their condition. leading to cancer and substantial loss of lung function. severe respiratory disease may ensue. many of which are acute in nature. the lungs are exposed to the outside environment. In the case of allergies. For most affected persons. require immediate medical administration of oxygen and ultimately mechanical ventilation in order to prevent lung collapse and death. decompression sickness. 159 . First.
These substances provoke both allergic and nonallergic forms of the disease. Adults who develop asthma may also have chronic rhinitis. second. aspirin. Although an initial episode can occur at any age. In 160 . coughing. and exercise may cause it as well. that may induce an allergic reaction.7 The Respiratory System 7 particles of foreign substances such as pollen may be deposited directly in the lungs. women are affected more often than men. It is therefore not surprising to find that sensitivity phenomena are common and represent an important aspect of pulmonary disease as a whole. however. In adults. third. such as pollen. approximately half of all cases occur in persons younger than age 10. and grains. Asthmatic episodes may begin suddenly or may take days to develop. stress may exacerbate symptoms. In addition. or sinusitis. and. chest tightness. it is often associated with an inherited susceptibility to allergens— substances. such as chemicals. boys being affected more often than girls. 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. or animal dander. dust mites. When asthma develops in childhood. the lung contains a very large vascular bed. and breathlessness that range in severity from mild to life-threatening. weather conditions. nasal polyps. asthma may develop in response to allergens. Adult asthma is sometimes linked to exposure to certain materials in the workplace. The most common and most important of these is asthma. which may be involved in any general inflammatory response. Asthma Asthma is a chronic disorder of the lungs in which inflamed airways are prone to constrict. causing episodes of wheezing. Among adults. wood dusts. but viral infections.
in general 161 . symptoms will subside if the causative agent is removed from the workplace. Encyclopædia Britannica. moderate persistent. and severe persistent. terminal bronchial tubes. most of these cases.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 During normal breathing. smooth muscles that surround the airways spasm. swelling and inflammation of the inner airway space (lumen) cause fluid buildup and infiltration by immune cells and excessive secretion of mucus into the airways. narrower passages (bronchioles) and finally into the tiny. Asthma is classified based on the degree of symptom severity. During an asthma attack. inhaled air travels through two main channels (primary bronchi) that branch within each lung into smaller. mild persistent. which can be divided into four categories: mild intermittent. air is obstructed from circulating freely in the lungs and cannot be expired. which results in tightening of the airways. Consequently. Although the mechanisms underlying an asthmatic episode are not fully understood. Inc.
which are anti-inflammatory medications often prescribed for children. which are involved in mediating airway constriction and inflammation. bronchodilators. mucus-clogged airways act as a one-way valve (i.. These medications may be taken on a long-term daily basis to maintain and control persistent asthma (long-term control medications). or they may be used to provide rapid relief from constriction of airways (quick-relief medications).7 The Respiratory System 7 it is known that exposure to an inciting factor stimulates the release of chemicals from the immune system.g.e. and excessive secretion of mucus into the airways. The inflamed. The obstruction of airflow may resolve spontaneously or with treatment.. These 162 . which interrupt the chemical signaling within the body that leads to constriction and inflammation. which are bronchodilators. long-acting beta2-agonists and methylxanthines (e. Quick-relief medications may include bronchodilators. A number of medications are used to prevent and control the symptoms of asthma and to reduce the frequency and severity of episodes. which relax smooth muscle constriction and open the airways. swelling and inflammation of the bronchial tubes. air is inspired but cannot be expired). theophylline). or systemic corticosteroids. Asthma medications are categorized into three main types: anti-inflammatory agents. and leukotriene modifiers. which suppress inflammation. which are the most potent and effective anti-inflammatory medications available. and zileuton and zafirlukast. Long-term control medications include corticosteroids. cromolyn sodium and nedocromil. such as shortacting beta2-agonists and ipratropium bromide. which are leukotriene modifiers. Agents that block enzymes called phosphodiesterases. These chemicals can cause spasmodic contraction of the smooth muscle surrounding the bronchi. are in clinical trials.
163 . Air pollution. a species of hookworm. persons who suffer from the disease are advised to minimize their exposure to the substances that trigger asthma. In those areas. Reasons for this dramatic surge in asthma cases. smoking. the number of asthma cases has increased steadily. Further investigation of this “helminthic therapy” in larger sample populations is under way. In developed countries and especially in urban areas. In addition to managing asthma with medications. particularly among children. very few people are affected by allergies or asthma. which may cause cardiovascular damage.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 drugs are designed to be long-lasting—administered once per day via inhalation—and are expected to be safer than traditional medications. and even cockroaches have been blamed for the increase. In 2006 a clinical trial conducted in a small number of patients demonstrated that deliberate infection with 10 hookworm larvae. The ability to recognize the early warning signs of an impending episode is important. A person with this condition must be hospitalized to receive oxygen and other treatment. can relieve symptoms of allergy and asthma. too few to cause hookworm disease. and individuals can monitor the level of airflow obstruction in their lungs by using a pocket-size device called a peak flow meter. Studies have shown that hookworms reduce the risk of asthma by decreasing the activity of the human host’s immune system. in many underdeveloped tropical regions of the world. A prolonged asthma attack that does not respond to medication is called status asthmaticus. exposure to secondhand smoke. crowded living conditions. However. millions of people are infected with Necator americanus. are not entirely clear. Today asthma affects more than 7 percent of children and about 9 percent of adults.
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). is a common seasonal condition caused by allergy to grasses and pollens. may give rise to asthma. shows a familial tendency and may be associated with other allergic disorders. desensitization by injections of an extract of the causative pollen administered once or twice a week for one or more years. Hay Fever Hay fever. such as dermatitis or asthma. The most effective long-term treatment is immunotherapy. Antibiotics may also interfere with immune development. like other allergic diseases. chiefly those depending upon the wind for cross-fertilization. nasal congestion. also known as allergic rhinitis. Symptoms may be aggravated by emotional factors. such as ragweed in North America and timothy grass in Great Britain.7 The Respiratory System 7 There has been some controversy concerning increased rates of asthma in countries where childhood vaccination is widespread. Children who are given broad-spectrum antibiotics (effective against multiple microorganisms) before two years of age are three times more likely to develop asthma than are children who are not given such antibiotics. Seasonally recurrent bouts of sneezing. Antihistamine drugs and inhaled corticosteroids provide symptomatic relief. In a reverse scenario. In allergic persons contact with pollen releases histamine from the tissues. and tearing and itching of the eyes caused by allergy to the pollen of certain plants. which irritates the small blood vessels and mucus-secreting glands. Hay fever. 164 . Although not yet successfully confirmed. studies have indicated that only one vaccine. pertussis vaccine.
Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America. Broman—Root Resources 165 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Giant ragweed (Ambrosia trifida) is a common cause of hay fever. Louise K.
or aggregations of giant cells. and canaries. with shortness of breath persisting after the radiographic changes have disappeared. in the west of England. and a greater or lesser degree of airflow obstruction due to smooth muscle contraction. on the eastern seaboard of Canada. In more chronic forms of the condition.7 The Respiratory System 7 Hypersensitivity Pneumonitis Hypersensitivity pneumonitis is an important group of conditions in which the lung is sensitized by contact with a variety of agents and in which the response to reexposure consists of an acute pneumonitis. or becoming opaque) in the basal regions of the lung on the chest radiograph. granulomas. alveolar wall edema. and there may be measurable interference with diffusion of gases across the alveolar wall. An acute hypersensitivity pneumonitis may also occur in those cultivating mushrooms (particularly where this is done below ground). with inflammation of the smaller bronchioles. budgerigars (parakeets). A similar group of diseases occurs in those with close contact with birds. and in France. Education of farmers and their families and the wearing of a simple mask can completely prevent the condition. One of these illnesses is the so-called farmer’s lung. Variously known as pigeon breeder’s lung or bird fancier’s lung. particularly proteins contained in the excreta of pigeons. Farmer’s lung is common in Wisconsin. these represent different kinds of allergic responses to proteins from birds. If untreated. Airflow obstruction in small airways is present. Inflammation can lead to widespread lung fibrosis and chronic respiratory impairment. This causes an acute febrile illness with a characteristically fine opacification (clouding. after 166 . may be found in the lung. caused by the inhalation of spores from moldy hay (thermophilic Actinomyces). the condition may become chronic.
Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. The disease may present as an atypical nonbacterial pneumonia and may be labeled a viral pneumonia if careful inquiry about possible contacts with known agents is not made. but sometimes the precise agent cannot be identified. or in response to a variety of other agents. It is occasionally attributable to Aspergillus. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Some species of the fungi genus Aspergillus can cause allergic reactions and mild pneumonia in susceptible individuals.
7 The Respiratory System 7 irritants. Asbestos. while milder irritants produce symptoms of lung disease only with massive exposure. Typically. chronic bronchitis. silica. produce grave reactions. The total dust load in the lung. and emphysema in the most severe cases. and coal dusts are other inorganic substances known to produce pneumoconiosis. encountered in numerous occupations. The lung diseases that result from the inhalation of such irritants are known medically as pneumoconioses. Inhaled dust collects in the alveoli. the early symptoms of mild pneumoconioses include chest tightness. clay. usually over a prolonged period of time. As little as 5 or 6 grams (about 0. Graphite. causing an inflammatory reaction that converts normal lung tissue to fibrous scar tissue and thus reduces the elasticity of the lung. small quantities of some substances. and the clinical symptoms of pneumoconiosis are manifested. the toxic effects of certain types of dust. shortness of breath. If enough scar tissue forms. Among inorganic dusts.2 ounce) in the lung can produce disease. notably silica and asbestos. barium. of the lung. is the most common cause of severe pneumoconiosis. Much evidence indicates that the smoking of cigarettes in particular aggravates the symptoms of many of the pneumoconiosis diseases. Pneumoconioses associated with these substances usually result only from continued exposure over long periods. although silica exposure is also involved in many cases. iron. The type and severity of disease depends on the composition of the dust. and cough. progressing to more serious breathing impairment. beryllium. lung function is seriously impaired. and aluminum dusts can cause a more severe pneumoconiosis. often after relatively brief 168 . and infections of the already damaged lung can accelerate the disease process. chromate. tin. or air sacs.
and their irritant effect may cause large amounts of fluid to accumulate in the lungs. when inhaled. The 169 . or hemp that. 10 to 20 years of occupational exposure to silica dust are needed for silicosis to develop. ammonia. and barley can produce lung disease through a severe allergic response within a few hours of exposure. quarry workers. sugarcane. and chloride. The chemicals themselves may scar the delicate lung tissues. having been recognized in knife grinders and potters in the 18th century. Once exposure to the chemical ceases. tunnelers. and workers whose jobs involve grinding. caused by fibres of cotton. Brown lung disease in textile workers is also a form of pneumoconiosis. even in previously nonallergic persons. stimulate histamine release. In most instances. Silicosis Silicosis is a chronic disease of the lungs that is caused by the inhalation of silica dust over long periods of time. Silicosis is one of the oldest industrial diseases. Chemical irritants that have been implicated in lung disease include sulfur dioxide. polishing. Asbestosis has also been associated with cancers of the lung and other organs. (Silica is the chief mineral constituent of sand and of many kinds of rock. impeding exhalation. and buffing. and it remains one of the most common dust-induced respiratory diseases in the developed world. Prolonged exposure to organic dusts such as spores of molds from hay. sandblasting. flax. stonecutters. mushrooms. malt. the patient may recover completely or may suffer from chronic bronchitis or asthma. acid. nitrogen dioxide.) The disease occurs most commonly in miners. which are quickly absorbed by the lining of the lungs. Histamines cause the air passages to constrict.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 exposure to massive amounts of dust.
The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses.000.0004 inch) in diameter penetrate to the finer air passages of the lungs. and particles of one to three microns do the most damage. control of the disease lies mainly in prevention. that serve to protect the body from bacterial invasion.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. called macrophages. These whorls of fibrous tissue may spread to involve the area around the heart. though this has changed with the availability of drug therapies for that disease. There is no cure for silicosis. also known as coal-worker’s pneumoconiosis. the openings to the lungs. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. In the past a large proportion of sufferers of silicosis died of tuberculosis. and weakness. Black Lung Black lung. emphysema. and pneumonia.000 particles of silica per cubic foot (about 210. The use of protective face masks and proper ventilation in the workplace and periodic X-ray monitoring of workers’ lungs has helped lessen the incidence of the disease. and. Silica particles. is a respiratory disorder caused by repeated inhalation of 170 . In the actual disease process. cannot be digested by the macrophages and instead kill them. Only very small silica particles less than 10 microns (0. difficulty in breathing. Silicosis predisposes a person to tuberculosis. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. since there is no effective treatment. however.000 per litre) of air. and gas exchange is poor. and the abdominal lymph nodes. The symptoms of silicosis are shortness of breath that is followed by coughing. Lung volume is reduced.
It may be the best known occupational illness in the United States. The disease is most commonly found among miners of hard coal. a German mineralogist. 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. brake linings. There is strong evidence that tobacco smoking aggravates the condition.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 coal dust over a period of years. Onset of the disease is gradual. tuberculosis is also more common in victims of black lung. whether coal itself is solely responsible for the disease. The first disease recognized to be caused by asbestos was asbestosis. which causes similar symptoms. as coal dust often is contaminated with silica. however. but in its more advanced form it frequently is associated with pulmonary emphysema or chronic bronchitis and can be disabling. Georgius Agricola. and as a fire protectant sprayed inside buildings. Symptoms usually appear only after 10 to 20 years of exposure to coal dust. The early stages of the disease (when it is called anthracosis) usually have no symptoms. first described lung disease in coal miners in the 16th century. It is not clear. Asbestosis and Mesothelioma The widespread use of asbestos as an insulating material during World War II. and it is now widely recognized. ceiling tiles. and the extent of disease is clearly related to the total dust exposure. Later it was discovered that exposure to much less asbestos than was needed to cause asbestosis led to 171 . led to a virtual epidemic of asbestos-related disease 20 years later. but it also occurs in soft-coal miners and graphite workers. The disease gets its name from a distinctive blue-black marbling of the lung caused by accumulation of the dust. and later in flooring.
All 172 . inhalation of asbestos remains a significant risk for the workers removing the material. The risks from smoking and from significant asbestos exposure are multiplicative in the case of lung cancer. Asbestos has been suspected to play a role in stimulating certain cellular events. Not all types of asbestos are equally dangerous. But exposure to any type of asbestos is believed to increase the risk of lung cancer. although in occasional cases pleuritis is very aggressive and thus may produce symptoms. and. As far as is known. Often a period of 20 years or more elapses between exposure to asbestos and the development of a tumour. A malignant tumour of the pleura known as mesothelioma is caused almost exclusively by inhaled asbestos. These events could contribute to the scarring and fibrosis that are characteristic of inhalation of asbestos fibres. such as the generation of harmful reactive molecules and the activation of damaging inflammatory processes. when both cigarette smoking and asbestos exposure occurred. but survival after diagnosis is less than two years. thickening of the pleura is not associated with disturbance of lung function or with symptoms of exposure to asbestos. The risk of mesothelioma in particular appears to be much higher if crocidolite. all the respiratory changes associated with asbestos exposure are irreversible. a blue asbestos that comes from South Africa. While the removal of asbestos from buildings has greatly alleviated the risk of exposure to asbestos for many people.7 The Respiratory System 7 thickening of the pleura. In most cases. It is not yet understood exactly why asbestos devastates the tissues of the lungs. there was a major increase in the risk for lung cancer. Malignant mesothelioma is rare and unrelated to cigarette smoking. is inhaled than if chrysotile is inhaled. especially when associated with cigarette smoking.
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industrialized countries have imposed strict regulations for handling asbestos, and the workforce is generally aware of the material’s dangers. There is no curative therapy for asbestosis or mesothelioma. Treatment is aimed at managing symptoms, preventing infections, and delaying disease progression. Individuals with asbestosis often receive annual vaccinations against influenza and pneumococcal pneumonia. In some cases, aerosol medications that thin mucous secretions and oxygen that is supplied by a portable tank are necessary to maintain adequate oxygen intake. In other cases, lung transplantation is required. Individuals with mesothelioma often undergo chemotherapy and radiation therapy, which may prolong survival for a short period of time.
Respiratory Toxicity of Glass and Metal Fibres
The increasing use of human-made mineral fibres (as in fibreglass and rock wool) has led to concern that these may also be dangerous when inhaled. Present evidence suggests that they do increase the risk of lung cancer in persons occupationally exposed to them. Standards for maximal exposure have been proposed. The toxicity of beryllium, known as berylliosis, was first discovered when it was widely used in the manufacture of fluorescent light tubes shortly after World War II. Although beryllium is no longer used in the fluorescent light industry, it is still important in the manufacture of metal alloys and ceramics. Berylliosis involves the lungs but occasionally affects only the skin. There are two forms: an acute illness occurring most frequently in workers extracting beryllium metal from ore or manufacturing
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.
comprise a diverse group of diseases and disorders. which occurs during mountain climbing and diving. toxic gases. Over time. account for an important set of illnesses that can contribute to severe respiratory dysfunction in persons of otherwise exceptional health. when the infarction is massive. which has usually formed in the veins of the legs or of the pelvis. The resulting pulmonary embolism leads to changes in the lung supplied by the affected artery. The causative factors of these conditions may include accidents. conditions arising from exposure to extremes in atmospheric pressure. to an increased respiratory rate. environmental pollutants. Circulatory Disorders The lung is commonly involved in disorders of the circulation. a clot is replaced with 177 . slight fever. ranging from poor pulmonary circulation to carbon monoxide poisoning. and occasionally some pleuritic pain over the site of the infarction. The most important and common of these is blockage of a branch of the pulmonary artery by blood clot. The consequences of embolism range from sudden death. these changes are known as a pulmonary infarction. Early mobilization after surgery or childbirth is considered an important preventive measure. When severe.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 other respiratory conditions Other respiratory conditions. in which the pressure in the main pulmonary artery is persistently increased. In addition. This occurs most often during a postoperative period when the affected individual is immobilized in bed. An individual is at an increased risk for pulmonary embolism whenever his or her circulation is sluggish. and metabolic disorders. Repetitive pulmonary emboli may lead to chronic pulmonary thromboembolism.
long-term evaluation and treatment. others such as prostacyclin are given by continuous intravenous infusion supplied through a portable battery-powered pump. affected individuals require careful. usually as a consequence of coronary arterial disease. In addition to chest X-rays and basic pulmonary function tests. thereby relieving symptoms of breathlessness. a condition of unknown origin. Primary pulmonary hypertension leads to enlargement of the heart and eventual failure of the right ventricle of the heart. While some medications such as calcium channel blockers may be taken orally. The obstructing lesions can be surgically removed in some instances. lung transplantation is necessary. ultimately. right ventricular heart failure. 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. causing shortness of breath on exertion and. a marked increase in pulmonary arterial pressure occurs as a result of progressive narrowing and obliteration of small pulmonary arteries. with consequent shortness of breath. and cardiac catheterization to measure pressure in the pulmonary artery and right ventricle of the heart. an echocardiogram to determine whether the heart is enlarged and to evaluate the flow of blood through the heart. Prostacyclin can sometimes be given in oral or inhaled forms. In primary pulmonary hypertension. When the 178 . Because of the variability in physiological response to certain drugs and because of the progressive nature of the disease. Congestion of the lungs (pulmonary edema) and the development of fluid in the pleural cavity. Treatment of primary pulmonary hypertension is aimed at alleviating symptoms. follows left ventricular failure. In some cases.7 The Respiratory System 7 an adherent fibrous material in the pulmonary arteries.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 valve between the left atrium of the heart and the left ventricle is thickened and deformed by rheumatic fever (mitral stenosis). The disorder arises because of a lack of surfactant. These changes contribute to the shortness of breath and account for the blood staining of the sputum. a pulmonary substance that prevents the alveoli from collapsing after the infant’s first breaths have been taken. It is characterized by extremely laboured breathing. respiratory distress syndrome of infants was frequently fatal.5 pounds). and abnormally low levels of oxygen in the arterial blood.5 kg. The syndrome was formerly the leading cause of death in premature infants. or approximately 5. Although respiratory distress syndrome occurs mostly in premature. Before the advent of effective treatment. In infants it is also called hyaline membrane disease. but considerable success in saving affected infants has been achieved by using mechanical ventilators that deliver air under pressure into the alveoli. low-birth-weight infants (those weighing less than 2. which does the work of the lungs by oxygenating the 179 . cyanosis (a bluish tinge to the skin or mucous membranes). particularly those born to diabetic mothers. The most seriously affected newborns are treated for several days with an extracorporeal membrane oxygenator. it also sometimes develops in full-term infants. Respiratory Distress Syndrome Respiratory distress syndrome is a condition that can affect infants or adults. This complication is especially common in premature newborns. chronic changes develop in the lung as a result of the increased pressure in the pulmonary circulation. 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.
7 The Respiratory System 7 blood and removing carbon dioxide. of the victims already had chronic heart or lung disease. Acute respiratory distress syndrome carries about a 50 percent mortality rate. Many. Most children who survive have no aftereffects. This episode spurred renewed attention to this problem. In adults. widespread bilateral lung injury. Many causes of respiratory distress syndrome of adults have been identified. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. Air Pollution The disastrous fog and attendant high levels of sulfur dioxide and particulate pollution (and probably also sulfuric acid) that occurred in London in the second week of December 1952 led to the deaths of more than 4. aspiration of material into the lung (including water in near-drowning episodes). but not all. This syndrome is known as acute respiratory distress syndrome of adults. exposure of the lung to gases. which had been intermittently considered since the 14th century 180 .000 people during that week and the subsequent three weeks. bacterial or viral pneumonia. Life-support treatment with assisted ventilation rescues many patients. 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. Recovery and repair of the lung may take months after clinical recovery from the acute event. although superimposed infection or multiple organ failure can result in death. It was recognized as “shock lung” in injured soldiers evacuated by helicopter to regional military hospitals during the Vietnam War. or any generalized septicemia (blood poisoning) or severe lung injury may lead to sudden. Prize cattle at an agricultural show also died in the same period as a result of the air pollution.
The large number of automobiles in that city. and finally the passage of legislation banning open coal burning. and possibly lung cancer. the factor most responsible for the pollution. together with the bright sunlight and frequently stagnant air. Today many industrial cities have legislation restricting the use of specific fuels and mandating emission-control systems in factories. respiratory tract infections in the young and old. This begins with the emission Air pollution begins as emissions from sources such as industrial smokestacks. In 1952 a different kind of air pollution was characterized for the first time in Los Angeles. leads to the formation of photochemical smog.com/Jupiterimages 181 .7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 in England. is associated with excess mortality and increased prevalences of chronic bronchitis. common in many cities using coal as heating fuel. This form of pollution. Photos. The pollutants released into the air may impact the respiratory health of people working in and living near such facilities.
A tightly sealed house may act as a reservoir for radon seeping in from natural sources. In controlled exposure studies it reduces the ventilatory capability of healthy people in concentrations as low as 0. leads to the formation of ozone and peroxyacetyl nitrite and other irritant compounds. there is much concern over the possible longterm consequences of brief but repetitive exposures to oxidants and acidic aerosols. and repeated exposures may lead to lung cancer.12 part per million. 182 . Such exposures are common in the lives of millions of people. and possibly the exacerbation of asthma occur as a result. chest irritation with cough. and finally. which begins as emissions of nitrogen oxides. where there is a high automobile density and the meteorologic conditions favour the formation of photochemical oxidants. These levels are commonly exceeded in many places. The indoor environment can be important in the genesis of respiratory disease. through a complex series of reactions in the presence of hydrocarbons and sunlight. In developed countries. Inhalation of tobacco smoke in the indoor environment by nonsmokers impairs respiration.7 The Respiratory System 7 of nitrogen oxide during the morning commuting hour. In developing countries. Although acute episodes of communal air exposure leading to demonstrable mortality are unlikely. Eye irritation. disease may be caused by inhalation of fungi from roof thatch materials or by the inhalation of smoke when the home contains no chimney. Bangkok. and São Paulo. Modern air pollution consists of some combination of the reducing form consequent upon sulfur dioxide emissions and the oxidant form. including Mexico City. and the impact of these exposures is an area of intense scientific investigation. followed by the formation of nitrogen dioxide by oxygenation. Ozone is the most irritant gas known. exposure to oxides of nitrogen from space heaters or gas ovens may promote respiratory tract infections in children.
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. 183 . as part of his detailed analysis of atmospheres in underground mines. the subject feels dizzy and is unable to perform simple tasks. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. Carbon monoxide is produced by incomplete combustion. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. including combustion of gas in automobile engines. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). Judgment is also impaired.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. 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. For this reason. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. A 4 percent increase in the blood carbon monoxide level in patients with coronary artery disease is believed to shorten the duration of exercise that may be taken before chest pain is felt. a condition in which hemoglobin is deficient. leaving only 60 percent available to bind to oxygen).
Both respiratory and metabolic acidosis can be life-threatening and often require immediate medical attention. certain drugs or poisons. Metabolic alkalosis results from either acid loss. which may be caused by anxiety. Causes of metabolic acidosis include uncontrolled diabetes mellitus. or low level of alkalinity. which may be caused by severe vomiting or by the use of potent diuretics (substances that promote production of urine). There are two primary types of acidosis: respiratory and metabolic. and renal failure. pulmonary embolism. in the body fluids. including the blood.7 The Respiratory System 7 Acidosis Acidosis is an abnormally high level of acidity. shock. Respiratory acidosis results from inadequate excretion of carbon dioxide from the lungs. Hyperventilation is defined as a sustained abnormal increase in breathing. or by certain medications that suppress respiration in excessive doses. This may be caused by severe acute or chronic lung disease. Alkalosis and Hyperventilation Alkalosis is an abnormally low level of acidity. or pneumonia. in the body fluids. such as general anesthetic agents. or high level of alkalinity. Respiratory alkalosis results from hyperventilation. During hyperventilation the rate of 184 . 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. including the blood. among others. such as pneumonia or emphysema. or bicarbonate gain. Alkalosis may be either metabolic or respiratory in origin. which may be caused by excessive intake of bicarbonate or by the depletion of body fluid volume. congestive heart failure. asthma.
Imbalances in the exchange of these gases can lead to dangerous respiratory disorders. 185 . In addition.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The alveoli and capillaries in the lungs exchange oxygen for carbon dioxide. Inc. causing symptoms such as shortness of breath. accumulation of fluid in the alveolar spaces can interfere with gas exchange. Encyclopædia Britannica. such as respiratory acidosis or hyperventilation.
The Respiratory System
removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, respiratory alkalosis ensues. In turn, alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, including light-headedness and tingling of the fingertips. Severe hyperventilation can cause transient loss of consciousness. Anxiety is the most common cause of hyperventilation. Panic disorder, a severe episodic form of anxiety, usually causes hyperventilation with resultant symptoms. Treatment of recurrent hyperventilation begins with a complete explanation by the patient of the condition and the symptoms it causes. Some people benefit from psychotherapy and medications to deal with the underlying anxiety.
Hypoxia is a condition of the body in which the tissues are starved of oxygen. In its extreme form, where oxygen is entirely absent, the condition is called anoxia. There are four types of hypoxia: (1) the hypoxemic type, in which the oxygen pressure in the blood going to the tissues is too low to saturate the hemoglobin; (2) the anemic type, in which the amount of functional hemoglobin is too small, and hence the capacity of the blood to carry oxygen is too low; (3) the stagnant type, in which the blood is or may be normal but the flow of blood to the tissues is reduced or unevenly distributed; and (4) the histotoxic type, in which the tissue cells are poisoned and are therefore unable to make proper use of oxygen. Diseases of the blood, the heart and circulation, and the lungs may all produce some form of hypoxia.
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
The hypoxemic type of hypoxia is due to one of two mechanisms: 1. a decrease in the amount of breathable oxygen—often encountered in pilots, mountain climbers, and people living at high altitudes— due to the reduced barometric pressure, or 2. cardiopulmonary failure in which the lungs are unable to efficiently transfer oxygen from the alveoli to the blood. In the case of anemic hypoxia, either the total amount of hemoglobin is too small to supply the body’s oxygen needs, as in anemia or after severe bleeding, or hemoglobin that is present is rendered nonfunctional. Examples of the latter case are carbon monoxide poisoning and methoglobinuria, in both of which the hemoglobin is so altered by toxic agents that it becomes unavailable for oxygen transport, and thus of no respiratory value. Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock. Local stagnant hypoxia may be due to any condition that reduces or prevents the circulation of the blood in any area of the body. Examples include Raynaud disease and Buerger disease, which restrict circulation in the extremities; the application of a tourniquet to control bleeding; ergot poisoning; exposure to cold; and overwhelming systemic infection with shock. In histotoxic hypoxia the cells of the body are unable to use the oxygen, although the amount in the blood may be normal and under normal tension. Although
The Respiratory System
characteristically produced by cyanide, any agent that decreases cellular respiration may cause it. Some of these agents are narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents.
Altitude sickness, sometimes called mountain sickness, is an acute reaction to a change from sea level or other lowaltitude environments to altitudes above 2,400 metres (8,000 feet). Altitude sickness was recognized as early as the 16th century. In 1878 French physiologist Paul Bert demonstrated that the symptoms of altitude sickness are the result of a deficiency of oxygen in the tissues of the body. Mountain climbers, pilots, and persons living at high altitudes are the most likely to be affected. The symptoms of acute altitude sickness fall into four main categories: 1. respiratory symptoms such as shortness of breath upon exertion, and deeper and more rapid breathing; 2. mental or muscular symptoms such as weakness, fatigue, dizziness, lassitude, headache, sleeplessness, decreased mental acuity, decreased muscular coordination, and impaired sight and hearing; 3. cardiac symptoms such as pain in the chest, palpitations, and irregular heartbeat; and 4. gastrointestinal symptoms such as nausea and vomiting. The symptoms usually occur within six hours to four days after arrival at high altitude and disappear within two to five days as acclimatization occurs. Although most
7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions
people gradually recover as they adapt to the low atmospheric pressure of high altitude, some persons experience a reaction that can be severe and, unless they return to low altitude, possibly fatal. At higher altitudes, the air becomes thinner and the amount of breathable oxygen decreases. The lower barometric pressures of high altitudes lead to a lower partial pressure of oxygen in the alveoli, or air sacs in the lungs, which in turn decreases the amount of oxygen absorbed from the alveoli by red blood cells for transport to the body’s tissues. The resulting insufficiency of oxygen in the arterial blood supply causes the characteristic symptoms of altitude sickness. The main protection against altitude sickness in aircraft is the use of pressurized air in cabins. Mountain climbers often use a mixture of pure oxygen and air to relieve altitude sickness while climbing high mountains. In addition, the prophylactic use of the diuretic acetazolamide initiated two to three days before ascent may prevent or mitigate acute altitude sickness. A more serious type of altitude sickness, high altitude pulmonary edema (HAPE), occurs rarely among newcomers to altitude but more often affects those who have already become acclimated to high elevations and are returning after several days at sea level. In pulmonary edema, fluid accumulates in the lungs and prevents the victim from obtaining sufficient oxygen. The symptoms are quickly reversed when oxygen is given and the individual is evacuated to a lower area.
Barotrauma and Decompression Sickness
Barotrauma is any of several injuries arising from changes in pressure upon the body. Humans are adapted to live at an atmospheric pressure of 760 mm of mercury (the pressure at sea level), which differs from pressures experienced
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. Subsequent breaths delivered by the ventilator are then driven into the mediastinum (the space between the lungs). Pilots of unpressurized aircraft. Air pumped into the chest by the machine can overdistend and rupture a diseased portion of the lung. such as the ears. the external pressures upon his or her body decrease. In certain cavities of the body. such as the eardrum.7 The Respiratory System 7 in underwater environments and in the upper atmospheres of space. in solution. sinuses. and these dissolved gases come 190 . lungs. the pleural spaces. Most body tissue is either solid or liquid and remains virtually unaffected by pressure changes. When a pilot ascends to a higher altitude. For example. and torso. causing subcutaneous emphysema (the trapping of air under the skin or in tissues). At atmospheric pressure the body tissues contain. and intestines. sudden expansion of air trapped within the thorax can burst one or both lungs. if a person in a deeply submerged submarine rapidly surfaces without exhaling during the ascent. A fatal form of barotrauma can occur in submariners and divers. small amounts of the gases that are present in the air. face. Another form of barotrauma may occur during mechanical ventilation for respiratory failure. or under the skin of the neck. however. underwater divers. there are air pockets that either expand or contract in response to changes in pressure. Abrupt expansion or contraction of closed internal air spaces can injure or rupture surrounding tissues. 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.
pain is usually severe and mobility is restricted. or peripheral nerves can cause paralysis and convulsions (diver’s palsy). the “chokes. nausea. the excess nitrogen is released. The oxygen breathed is used up by the cells of the body and the waste product carbon dioxide is continuously exhaled. The lung plays a significant role in the pathogenesis and natural history of this illness and may contribute to the clinical picture. as the affected person commonly is unable to straighten joints. Conversely. Therefore. Small nitrogen bubbles trapped under the skin may cause a red rash and an itching sensation known as diver’s 191 . Bubbles forming in the brain. rapid respiration. signals the onset of pulmonary decompression sickness. tissues with a high fat content (lipids) tend to absorb more nitrogen than do other tissues. Shallow. nitrogen merely accumulates in the body until the tissue becomes saturated at the ambient pressure. The gases then pass to the respiratory tract and are exhaled from the body. 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.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 out of solution. spinal cord. speech defects. Nitrogen is much more soluble in fatty tissue than in other types. difficulties with muscle coordination and sensory abnormalities (diver’s staggers). often associated with a sharp retrosternal pain on deep inspiration.” The major component of air that causes decompression maladies is nitrogen. numbness. and personality changes. The nervous system is composed of about 60 percent lipids. the gases have time to diffuse from the tissues into the bloodstream. When the pressure decreases. If the ascent is slow enough. When bubbles accumulate in the joints. The term bends is derived from this affliction.
a burning sensation while breathing. If one descends to a depth of about 30 metres (100 feet). is a type of barotrauma involving compression of the lungs and thoracic cavity. or lung squeeze. Because the lung tissue is elastic and interspersed with tubules and sacs of air. it is capable of some enlargement when air is inhaled and some shrinkage when it is exhaled. The outer linings of the lungs (pleural sacs) may separate from the chest wall. Excessive coughing and difficulty in breathing. and the size of the lungs decreases. but this process is not always able to reverse damage to tissues. known as the chokes. Thoracic Squeeze Thoracic squeeze. while too little air causes compression and collapse of the lung walls. the lung shrinks to about one-fourth its size at the surface. 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). Excessive compression of the lungs in this manner causes tightness and pain in the thoracic cavity.7 The Respiratory System 7 itches. indicate nitrogen bubbles in the respiratory system. Too much air causes rupture of lung tissue. Other symptoms include chest pain. and the lung may collapse. an increase in pressure causes air spaces and gas pockets within the body to compress. the air inside the lungs is compressed. and severe shock. Relief from decompression sickness usually can be achieved only by recompression in a hyperbaric chamber followed by gradual decompression. If compression continues. During the descent. the delicate lung tissue may rupture and allow tissue fluids to enter the lung spaces and tubules. It most commonly occurs during a breath-holding dive underwater. 192 . Usually these symptoms pass in 10 to 20 minutes.
even when reduced. and may even become unconscious. their lungs. Artificial respiration may be necessary if the breathing has stopped. 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. Any symptoms of thoracic squeeze call for prompt medical attention. Until recently. A fuller appreciation of the 193 . do not separate from the chest wall. or breathing—at the time of rescue.000 metres (3. Water closing over the victim’s mouth and nose cuts off the body ’s supply of oxygen. and their bodies are adapted to use the gases in the bloodstream more conservatively. and gives up the remaining tidal air in his or her lungs. physically and intellectually. Deprived of oxygen the victim stops struggling. There the heart may continue to beat feebly for a brief interval. loses consciousness. Drowning Drowning is suffocation by immersion in a liquid. It is now known that victims immersed for an hour or longer may be totally salvageable. These aquatic mammals have been found to have more elastic chest cavities than humans. although they lack evidence of life. pulse. having no measurable vital signs—heartbeat. may exhale frothy blood.300 feet). the diver may have difficulty in breathing. If the thoracic squeeze has been sufficient to cause lung damage. but eventually it ceases. usually water.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 The predominant symptom felt by the diver is pain when the pressure becomes too great. more than 10 times the depth that humans can tolerate. which can be relieved by ascending. 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. The sperm whale is reported to dive to about 1.
194 . despite a total absence of respiratory gas exchange. so that many people who once would have been given up for dead are being saved. When aspiration does occur. abdomen. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. enhances survival during submersion. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. known as the mammalian diving reflex. Often. the volume of fluid entering the lungs rarely exceeds a glassful. quantities of water are swallowed and later vomited spontaneously or during resuscitative procedures. actual aspiration of water into the lungs may or may not occur. The mechanism is powerful in children. Even though the heart functions at a slower rate. and surface areas of the body to the heart and the brain. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. Actual arrest of circulatory processes is a relatively late development in the drowning sequence.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. Up to 15 percent of drownings are “dry. thus permitting seagoing mammals to hunt for long periods underwater. Scientists have determined that vestiges of the reflex persist in humans. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. In this suspended state. A natural biological mechanism that is triggered by contact with extremely cold water. It diverts blood from the limbs. in other respects it performs normally.
slows the heart rate. 195 . None of these effects is imminently life-threatening. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain.6 °F (17 °C) have survived. Rescue teams now continue the benefits of cold-water protection with “therapeutic hypothermia.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 In warm water the body’s need for oxygen is increased. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. survival following hypothermic coma is almost 75 percent. and promotes unconsciousness. Such warmwater drownings occur commonly in domestic bathtubs. 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).” “Lifeless” immersion victims with core temperatures as low as 62.
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. many technological advances. have contributed to improvements in the diagnosis and evaluation of respiratory disease. physiology. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. In addition.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy. A cough productive of sputum is the most important manifestation of inflammatory or 196 . 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. drugs such as decongestants and antibiotics have substantially improved the treatment of allergic and infectious respiratory diseases. This instrument enabled physicians to more precisely diagnose diseases of the chest and heart. This expansion of scientific understanding has enabled important progress in respiratory medicine. Likewise. especially in the area of disease prevention. and pathology of the human respiratory system is known as pulmonology. particularly concerning techniques employing X-ray imaging or endoscopy. Today. or respiratory medicine.
30 to 60 ml of sputum are produced in a 24-hour period. as when a foreign body is inhaled into the trachea. of complex origin. capillary damage. or shortness of breath. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. and tasks such as dressing cannot be performed without difficulty. Hemoptysis is also a classic sign of tuberculosis of the lungs. in which there is irreversible lung damage. it may also indicate the presence of inflammation. playing golf. More often. may arise acutely. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. resulting from occupational lung disease or arising from no identifiable antecedent condition. In severe bronchitis the mucous glands lining the bronchi enlarge greatly. it is constantly present. and fluid may accumulate in 197 . or with the onset of a severe attack of asthma. the lung capillaries become engorged. and. or walking uphill. may also cause severe and unremitting dyspnea. of which bronchitis is a common example. The second most important symptom of lung disease is dyspnea. 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. When this occurs. It may become so severe as to immobilize the victim. What is noted is a slowly progressive difficulty in completing some task. such as walking up a flight of stairs. Severe fibrosis of the lung. commonly. if the right ventricle that pumps blood through the lungs is functioning normally. or a tumour. This sensation. but in diseases such as emphysema. particularly in the first two hours after awakening in the morning. it is insidious in onset and slowly progressive. The shortness of breath may vary in severity.7 Approaches to Respiratory Evaluation and Treatment 7 malignant diseases of the major airways.
in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. For example. and chest pain—may be added several others. such as a mesothelioma. A wheeziness in the chest may be heard. such as occurs in asthma.7 The Respiratory System 7 small alveoli and airways.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways). severe chest pain may be caused by the spread of malignant disease to involve the pleura. Sudden blockage of a blood vessel injures the lung tissue to which the vessel normally delivers blood. pulmonary embolism. a small lung cancer that is not obstructing an airway does not produce shortness of breath. diffuse 198 . or by a tumour that arises from the pleura itself. dyspnea. intractable pain caused by such conditions may require surgery to cut the nerves that supply the affected segment. Fortunately. a condition known as a pleural effusion. This is caused by narrowing of the airways. The pain disappears when fluid accumulates in the pleural space. Severe. Chest pain may be an early symptom of lung disease. To these major symptoms of lung disease—coughing. Pain associated with inflammation of the pleura is characteristically felt when a deep breath is taken. since. In addition. which leads to acute congestion of the affected part. Some diseases of the lung are associated with the swelling of the fingertips (and. can cause pleurisy. but it is most often associated with an attack of pneumonia. Acute pleurisy with pain may signal a blockage in a pulmonary vessel. for example. 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. pain of this severity is rare. rarely. It is commonly dyspnea that first causes a patient to seek medical advice. but absence of the symptom does not mean that serious lung disease is not present. of the toes) called “clubbing.
since a peripheral neuropathy may also be the presenting evidence of these tumours. as it may reveal the presence of an area of inflammation. for example. this unusual sign may disappear after surgical removal of the tumour. the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. especially in the early stage. or jaundice from liver involvement may all be the first evidence of a primary lung cancer. the first symptom may be a swelling of the lymph nodes that drain the affected area. Methods of inVestigation Physical examination of the chest remains important. a 199 . are variable and nonspecific. and some symptoms apparently unrelated to the lung. particularly the small nodes above the collarbone in the neck. physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints. enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. may be diverse indicators of lung disease. Not infrequently. such as mild indigestion or headaches. In the case of lung cancer. may be conscious of only a general feeling of malaise. A person with active lung tuberculosis or with lung cancer. In some lung diseases. a hip fracture from bone metastases. unusual fatigue. The generally debilitating effect of many lung diseases is well recognized. Loss of appetite and loss of weight. Thus. the patient may feel as one does when convalescent after an attack of influenza. general psychological depression. Not infrequently. a disinclination for physical activity. or seemingly minor symptoms as the first indication of disease. and lung cancer. as may sensory changes in the legs. Because the symptoms of lung disease.7 Approaches to Respiratory Evaluation and Treatment 7 fibrosis of the lung from any cause. cerebral signs from intracranial metastases.
and auscultation (listening) with a stethoscope to determine pitch and loudness of breath sounds. Although magnetic resonance imaging (MRI) plays a limited role in examination of the lung. Methods of examination include physical inspection and palpation for masses. lung ventilation and perfusion scanning can also be helpful in detecting abnormalities of the lungs. Examination of the sputum for bacteria allows the identification of many infectious organisms and the institution of specific treatment. The combined results from ventilation and perfusion scanning are important for the detection of focal occlusion of pulmonary blood vessels by pulmonary emboli. The conventional radiological examination of the chest has been greatly enhanced by the technique of computerized tomography (CT). and the perfusion scan allows visualization of the blood vessels in the lungs. in the case of perfusion scanning. or injected. The ventilation scan allows visualization of gas exchange in the bronchi and trachea. The sounds detected with a stethoscope may reveal abnormalities of the airways. percussion to gauge the resonance of the underlying lung. because the technique is not well suited to imaging air-filled spaces. 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. MRI is useful for imaging the heart and blood vessels within the 200 . the lung tissue. tender areas. While the resolution of computerized tomography is much better than most other visualization techniques. in the case of ventilation scanning. or an airway obstruction. or the pleural space. sputum examination for malignant cells is occasionally helpful. and abnormal breathing patterns.7 The Respiratory System 7 pleural effusion. a radioactive tracer molecule is either inhaled. In these techniques.
the measurement of the rate and quantity of air exhaled forcibly from a full respiration. A number of tests are available to determine the functional status of the lung and the effects of disease on pulmonary function. allows measurement of the ventilation capacity of the lungs and quantification of the degree of airflow obstruction. trachea. and after exercise. and the rate of gas transfer across the lung. which is often used in field studies. Tests of exercise capability. Tissue samples are examined for histological changes that indicate certain diseases and are cultured to determine whether harmful bacteria are present. 201 . By feeding a surgical instrument through a special channel of the bronchoscope. or the pressure required to inflate it. Ventilatory capability can be measured with a peak flow meter. airflow resistance. Arterial blood gases and pH values indicate the adequacy of oxygenation and ventilation and are routinely measured in patients in intensive care units. total ventilation. Positron emission tomography (PET) is used to distinguish malignant lung tissue from scar tissue on tissues such as the lymph nodes. which is commonly measured by recording the rate of absorption of carbon monoxide into the blood (hemoglobin has a high affinity for carbon monoxide). More complex laboratory equipment is necessary to measure the volumes of gas in the lung. are useful in assessing functional impairment and disability. physicians can collect fluid and small tissue samples from the airways. in which workload.7 Approaches to Respiratory Evaluation and Treatment 7 thorax. Spirometry. the distribution of ventilation within the lung. and major bronchi. and gas exchange are compared before. Flexible fibre-optic bronchoscopes that can be inserted into the upper airway through the mouth are used to examine the larynx. the stiffness of the lung. during.
or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs). There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. or the transfer of gas between the alveoli and the blood. and (2) those measuring respiratory function. David McNew/Getty Images Pulmonary Function Test A pulmonary function test is a procedure used to measure various aspects of the working capacity and efficiency of the lungs and to aid in the diagnosis of pulmonary disease. Tests of ventilatory function include the following measurements: residual 202 .7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction.
The image is made by passing X-rays through the body to produce a shadow image on specially sensitized film. of the lungs. all the other volumes may be recorded with a spirometer. who discovered X-rays in 1895. the resting lung volume. which is measured by a dilution method. vital capacity. The roentgenogram is named after German physicist Wilhelm Conrad Röntgen. maximum air volume that can be expelled after a maximum inspiration. expressed in litres of air per minute. maximal air volume expelled in 12 to 15 seconds of forced breathing. maximal flow rate of a single expelled breath. functional residual capacity (FRC). forced expiratory volume (FEV).7 Approaches to Respiratory Evaluation and Treatment 7 volume (RV). tidal volume. air remaining within the chest after a maximal expiration. 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. Except for the residual volume. or air within the chest at the end of a quiet expiration. maximum air volume expelled in a time interval. which measure the capacity of the lungs to move air in and out. and maximal expiratory flow rate (MEFR). taken to look for infections such as 203 . breathing movements may also be registered graphically on a spirogram. One of the most common screening roentgenograms is the chest film. and total lung capacity (TLC). This approach produces an image known as a roentgenogram (or X-ray image) of internal structures. include maximal voluntary ventilation (MVV). or capillaries. Chest X-ray X-ray imaging is a valuable diagnostic technique used in medicine. air volume within the chest in full inspiration. volume of a breath. Ventilation tests.
or VQ (ventilation quotient) scan.7 The Respiratory System 7 tuberculosis and conditions such as heart disease and lung cancer. unfortunately. the patient inhales a mixture of oxygen and nitrogen containing small amounts of radioactive xenon or technetium. the blockage of one of the pulmonary arteries or of a connecting vessel. Lung Ventilation/Perfusion Scan A lung ventilation/perfusion scan. 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. Lung ventilation/ perfusion scanning is used most often in the diagnosis of pulmonary embolism. The procedure is also used to accurately identify damaged regions of lung tissue prior to surgery to remove the tissue. Pulmonary embolism is caused by a clot or an air bubble that has become lodged within a vessel or by the accumulation of fat along the inner walls of the vessel. Lung ventilation/perfusion scanning uses radioisotopes to trace the movement of air and blood through the lungs. To track the movement of air. 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. thereby narrowing the passageway and hindering the flow of blood. but. Treatment of tuberculosis detected by a roentgenogram can prevent more extensive infection. This approach may be taken for patients with advanced or rapidly spreading lung cancer. is a test that measures both air flow (ventilation) and blood flow (perfusion) in the lungs. the patient receives an injection into the bloodstream of a radioactive albumin tracer (usually labeled 204 .
a mismatch between the two scans is indicative of disease. Nutrient deprivation renders the tissue highly susceptible to death. Thus.or blooddeprived. In contrast. Bronchoscopy Bronchoscopy is a medical examination of the bronchial tissues using a lighted instrument known as a bronchoscope. the tissues affected will be either oxygen. Areas in the images known as cold spots appear very dark and point to regions within the lungs where tracers are relatively scarce. The appearance of hot spots. In both ventilation and perfusion scans. 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. he or she may subsequently undergo more invasive procedures. Although the tracers used in lung ventilation/perfusion scanning are radioactive. highlight places within the lungs where air or blood have accumulated abnormally. In general. the ventilation and perfusion scans match for a person with healthy lungs. normal air and blood flow are reflected in the even distribution of tracers within the lungs. including angiography. If the results of lung ventilation/ perfusion scanning reveal that a patient is at high risk for pulmonary embolism.7 Approaches to Respiratory Evaluation and Treatment 7 with technetium). or areas where the tracers become highly concentrated and therefore produce bright areas in the images. and another set of images is taken with the scanner. the levels of radioactivity are exceptionally low and pose a very small risk to patients. The procedure is commonly used to aid the diagnosis of respiratory disease in persons with persistent 205 .
7 The Respiratory System 7 The trachea and major bronchi of the human lungs. 206 . Inc. Encyclopædia Britannica.
can be used to examine bronchial passageways down to the level of the tertiary bronchi—the smallest passages preceding the bronchioles. typically made of expandable wire mesh) or in the resection (removal) of tissue in cases in which cancerous growths block the airways. blood) to be removed during an examination. 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. which enables large volumes of fluid (e. 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. and to assist in the placement of stents (tubes. There are two types of bronchoscopes. Although rigid bronchoscopes have been replaced by flexible scopes for the majority of procedures. The second type of scope. known as a rigid bronchoscope. as well as in persons who have abnormal chest findings following computerized axial tomography scanning or X-ray examination. both flexible and rigid scopes have a channel through which instruments can be passed. In addition.g. they remain superior for specific applications. Flexible scopes. 207 .7 Approaches to Respiratory Evaluation and Treatment 7 cough or who are coughing up blood. All bronchoscopes can be fitted with a small video camera that enables real-time visualization of the procedure. The latter feature is commonly employed for biopsy—the collection of tissues for histological study.. Bronchoscopy is also employed to remove foreign objects from the airways. to deliver certain therapeutic agents directly into the lungs. consists of a metal tube that has a wide suction channel. because of their ability to bend and twist. A flexible bronchoscope may be passed through the nose to examine the upper airways or through the mouth to examine the trachea and lungs.
bleeding subsides without the need for medical intervention.7 The Respiratory System 7 Flexible bronchoscopy of the upper airways generally requires the use of a local anesthetic to numb the tissues. It fulfills an especially important role in the detection and diagnosis of cancers affecting the thoracic cavity. as well as a set of lymph nodes. Another risk factor associated with bronchoscopy is the introduction of infectious agents into the lungs. For example. upon waking. In addition. in which air enters the space between the pleural membranes lining the lungs and thoracic cavity. including nausea and vomiting. In contrast. however. because of the discomfort caused by the device. rigid bronchoscopy. trachea. causing them to bleed. there are several important risks associated with the bronchoscopy procedure itself. mediastinoscopy can be used to evaluate and diagnose a variety of thoracic diseases. esophagus. which occurs when the instrument is not sanitized properly. In most cases. the movement of a bronchoscope through the airways often scratches superficial tissues. and thymus gland. causing a condition known as pneumothorax. which can cause side effects in some people. including tuberculosis and sarcoidosis (a disease characterized by the formation of small grainy lumps within tissues). Mediastinoscopy Mediastinoscopy is a medical examination of the mediastinum using a lighted instrument known as a mediastinoscope. necessitates the use of general anesthesia. Because the region of the mediastinum contains the heart. serving as one of the primary 208 . Bleeding is especially common following biopsy. The bronchoscope or the removal of tissue for biopsy may lead to the perforation of lung tissue.
This may also be performed for other tissues in the region that display signs of disease. During mediastinoscopy. 209 . such as abnormal growths or inflammation. particularly for cellular defects associated with cancer and for the presence of infectious organisms. This step of the procedure is known as mediastinotomy. A mediastinoscope—a thin. infection. immediately above the sternum. Most patients recover within several days following mediastinoscopy. Mediastinoscopy is also frequently used in conjunction with noninvasive cancer-detection techniques. In cancer staging. The biopsy samples are then investigated for evidence of abnormalities. Staging involves the investigation of cells to assess the degree to which cancer has spread. Severe complications— such as bleeding. A video camera attached to the scope aids in the positioning of the instrument and in the visual examination of the tissues. the doctor is able to investigate the surfaces of the various structures.7 Approaches to Respiratory Evaluation and Treatment 7 methods by which tissue samples are collected from the mediastinal lymph nodes for the staging of lung cancer. and the procedure is associated with a very low risk of complications. By carefully maneuvering the scope in the space. a surgeon first makes a small incision in the patient’s neck. light-emitting. which is performed under general anesthesia. flexible instrument—is then passed through the incision and into the space between the lungs. or paralysis of the vocal cords—occur in approximately 1 to 3 percent of patients. pneumothorax (damage to the lungs that causes the leakage of air into the space between the lungs and thoracic cavity). including computerized axial tomography and positron emission tomography. tissue samples from the lymph nodes are collected by passing a biopsy instrument through a channel in the scope.
and antibiotics. 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. In addition. in which chest physiotherapy is used to facilitate clearing the airway of mucus or liquid secretion by suction. Postural drainage is a technique in which the forces of gravity are used to promote the drainage of obstructing secretions. as in treatment of cystic fibrosis. can also be administered in an inhaled mist by means of an ultrasonic nebulizer. Oxygen may be administered in controlled amounts to assist laboured breathing. such as bronchodilators. each of which may be tailored to a specific disease.7 The Respiratory System 7 types of respiratory therapy Respiratory therapy is primarily concerned with assisting or improving the respiratory function of individuals with acute or chronic lung disease. Water is a major therapeutic agent in bronchopulmonary disease and may be used in the form of cold steam. Ultrasonic equipment may be used to propel very fine particles directly into the lungs. Medications. 210 . adjustment. produces vibrations that help to loosen and mobilize secretions. mucolytics. and maintenance of mechanical ventilators. hot steam. Therapy may involve the administration of gases for inhalation. performed manually or by means of a handheld percussor or vest. or a fog (as in an oxygen tent or a croup tent). One of the conditions frequently dealt with is obstruction of breathing passages. Chest percussion. 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. respiratory therapists are experts in the setup. Other forms of respiratory therapy include the use of aerosol treatments to relieve bronchospasm.
and antibiotics. Though the use of antibiotics in the treatment of minor respiratory infections is today a controversial issue. that are of particular importance in the routine treatment of respiratory illness. Of special importance in the treatment of respiratory infections such as bacterial pneumonia is a class of antibiotics known as macrolides. decongestants shrink the mucous membranes lining the nasal cavity by contracting the muscles of blood vessel walls. there are three groups. However. veins. the arterioles. these agents remain valuable in reducing mortality rates from respiratory diseases that at one time caused certain death in humans. decongestants and antihistamines are available over the counter.7 Approaches to Respiratory Evaluation and Treatment 7 Drug Therapies There are many different types of drugs that may be used in the treatment of respiratory diseases. The constricting action chiefly affects the smallest arteries. The relative safety and efficacy of these drugs has made them generally reliable medications. and larger arteries respond to some degree. and thus they are used by many people. Antibiotics represent a group of drugs that revolutionized respiratory medicine following the introduction of penicillin in the 1940s. although capillaries. Decongestants are sympathomimetic agents. antihistamines. In countries such as the United States. decongestants. That is. Decongestants Decongestants are drugs used to relieve swelling of the nasal mucosa accompanying such conditions as the common cold and hay fever. When administered in nasal sprays or drops or in devices for inhalation. thus reducing blood flow to the inflamed areas. they mimic the effects of stimulation of the sympathetic 211 . due to the emergence of resistant organisms.
insomnia. or heart palpitations. Antihistamines Antihistamines are drugs that selectively counteract the pharmacological effects of histamine. however. Antihistamines replace histamine at one or the other of the two receptor sites at which it becomes bound to various susceptible tissues. an alkaloid originally obtained from the leaves of ma huang. inflammation.7 The Respiratory System 7 division of the autonomic nervous system. Because none of them has a sustained effect. thereby preventing histaminetriggered reactions under such conditions as stress. Ephedrine and other decongestants are made by chemical synthesis. in which epinephrine constricts the blood vessels of the skin. any of several species of shrubs of the genus Ephedra.000 years. a neurotransmitter produced by the adrenal gland that is released at sympathetic nerve endings when the nerves are stimulated. causing anxiety. results in absorption into the bloodstream. They include phenylephrine hydrochloride. following its release from certain large cells (mast cells) within the body. amphetamine and several derivatives. The effectiveness of the other decongestants results from their chemical similarity to epinephrine. too frequent use. The oldest and most important decongestant is ephedrine. and allergy. headache. they must be used repeatedly. They are therefore designated H1-blocking agents and oppose selectively all the pharmacological effects of 212 . and naphazoline hydrochloride. One of the chief drugs of the group is epinephrine. The effect of its decongestant action resembles the blanching of the skin that occurs with anger or fright. The antihistamines that were the first to be introduced are ones that bind at the so-called H1 receptor sites. which has been used in Chinese medicine for more than 5. dizziness.
Persons with urticaria. The first antihistamines were derivatives of ethylamine. edema. it is unlikely that he or she will benefit from them.7 Approaches to Respiratory Evaluation and Treatment 7 histamine except those on gastric secretion. 213 . Used in sufficiently large doses. and most are rendered inactive by monoamine oxidase enzymes in the liver. more specific. compounds that were more potent. Other side effects include gastrointestinal irritation. and certain sensitivity reactions respond well. and less toxic were prepared. and dryness of the mouth. antihistamines can control certain allergic conditions. nearly all antihistamines produce undesirable side effects. More than 100 antihistaminic compounds soon became available for treating patients. the forerunner of most modern antihistamines (an aniline derivative called Antergan) was discovered. In 1942. The incidence and severity of the side effects depend both on the patient and on the properties of the specific drug. tested later and found to be more potent. If a patient’s condition does not improve after three days of treatment with antihistamines. blurred vision. Antihistamines with powerful antiemetic properties are used in the treatment of motion sickness and vomiting. Nasal irritation and watery discharge are most readily relieved. The development of these antihistamines dates from about 1937. Antihistamines are not usually beneficial in treating the common cold and asthma. Because histamine is involved in the production of some symptoms of allergy and anaphylaxis. among them hay fever and seasonal rhinitis. when French researchers discovered compounds that protected animals against both the lethal effects of histamine and those of anaphylactic shock. itching. Anilinetype compounds. Antihistamines are readily absorbed from the alimentary tract. headache. The most common side effect in adults is drowsiness. subsequently. were too toxic for clinical use.
Some are highly specific..g. and they are especially important in the treatment of bacterial respiratory infections. such as the tetracyclines. are valuable in treating pharyngitis and pneumonia caused by Streptococcus in persons sensitive to penicillin. the bacillus responsible for diphtheria. The principle governing the use of antibiotics is to ensure that the patient receives one to which the target bacterium is sensitive.7 The Respiratory System 7 During the 1970s an H2-blocking agent. at a high enough concentration to be effective (but not cause side effects). They are also used in treating pneumonias caused either by Mycoplasma species or by Legionella pneumophila (the organism that causes Legionnaire disease). Macrolides are also used to treat pharyngeal carriers of Corynebacterium diphtheriae. cimetidine (Tagamet) was introduced. but they can be given parenterally. These drugs are usually administered orally. whereas others. Compounds of this class suppress histamine-induced gastric secretion and have proved extremely useful in treating gastric and duodenal ulcers. erythromycin. and for a sufficient length of time to ensure that the infection is totally eradicated. Antibiotics known as macrolides (e. which inhibit bacterial protein synthesis. Antibiotics vary in their range of action. in which tissues such as the 214 . act against a broad spectrum of different bacteria. azithromycin) are particularly effective in the treatment of bacterial respiratory infections. Macrolides. Antibiotics Antibiotics are among the most medically valuable drugs available in the modern era. Oxygen Therapy The medical administration of oxygen is an important means of treating respiratory disease. Oxygen therapy is used for acute conditions. clarithromycin.
such as chronic obstructive pulmonary disease (COPD). Another form of therapy. because the procedure can potentially stimulate the generation of DNA-damaging free radicals. HBOT has been promoted as an alternative therapy for certain conditions. oxygen may be administered by citizen responders via mouth-to-mouth breaths in cardiopulmonary resuscitation (CPR) or by emergency medical personnel via a face mask placed over the victim’s mouth and nose that is attached to a small. which is inserted directly into the trachea by way of a hole made surgically in the neck. In both the hospital and the home settings. 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. Some patients may require oxygen administration via a transtracheal catheter. a device inserted into the nostrils that is connected by tubing to an oxygen system. 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. In addition.7 Approaches to Respiratory Evaluation and Treatment 7 brain and heart are at risk of oxygen deprivation. 215 . as well as for chronic diseases that are characterized by sustained low blood oxygen levels (hypoxemia). These applications are controversial. however. For patients affected by chronic lung diseases. portable compressed-gas oxygen cylinder. employs a pressurized oxygen chamber (hyperbaric chamber) into which pure oxygen is delivered via an air compressor. known as hyperbaric oxygen therapy (HBOT). home oxygen therapy may be prescribed by a physician. oxygen may be delivered through a face mask or through a nasal cannula. In emergency situations.
Oxygen is usually administered in controlled amounts per minute. generally placed over the end of a finger. is used to indirectly determine hemoglobin saturation—the percent of hemoglobin molecules in the blood 216 . Oxygen concentrators. Flow rate is determined based on measurements of a patient’s blood oxygen levels. Stationary and portable oxygen concentrators have been developed for use in the home. as opposed to releasing gas constantly. Large stationary and small portable gas cylinders can be used in the hospital or the home. Oxygen also can be stored as a highly concentrated liquid. a probe. The stored oxygen can then be used by the patient when needed and is readily replenished. and carbon dioxide levels are measured. which maintain oxygen under high pressure and require the use of a regulator to modulate the flow of gas from the cylinder to the patient. In pulse oximetry. Oxygen turns to liquid only when it is kept at very cold temperatures. a measure known as the flow rate. Another form of oxygen storage is in compressed-gas cylinders. Liquid oxygen can be stored in small or large insulated containers. provide a method of storing oxygen at concentrations greater than that occurring in ambient air. which can be refilled at pharmacies or by delivery services. which necessitates more-frequent cylinder replacement. blood is drawn from an artery. Two tests that are commonly used to assess the concentration of oxygen in the blood include the arterial blood gas (ABG) test and the pulse oximetry test. oxygen. which draw in surrounding air and filter out nitrogen. When it is released under pressure from cold storage. it is converted to a gas. In the ABG test. Gas cylinders are often used in conjunction with oxygenconserving devices that prevent oxygen leakage from the cylinder by releasing gas only when the patient inhales.7 The Respiratory System 7 There are various stationary and portable oxygenstorage systems that can be used in the hospital or the home. and blood acidity.
adverse physiological effects may ensue if the flow rate is too high. HBOT is associated with an increased risk of barotrauma of the ear. Bleomycin damages cancer cells by stimulating the production of reactive oxygen species. the patient will not receive enough oxygen and could be at risk of injury from severe hypoxemia. the use of home oxygen therapy can reduce hospital admission and extend survival in patients with diseases such as COPD. premature infants who receive excessive amounts of oxygen in their first days of life may develop a blinding disorder known as retinopathy of prematurity. oxygen therapy does not alter the progression of lung disease. Bronchopulmonary dysplasia. Also. it does not appeal to some patients. a response that is amplified in the presence of excess oxygen. If oxygen flow rate is too low. For example. The difference between absorption readings during systole (when the heart contracts) and during diastole (when the heart relaxes) are used to calculate hemoglobin saturation. Compressed-gas cylinders present a significant safety hazard in the home as well. However. The device uses light-emitting diodes and a photodetector to measure light absorption in the capillaries. is characterized by absent or abnormal repair of lung tissue following high-pressure or excessive oxygen administration. Likewise. if they are not secured and stored 217 .7 Approaches to Respiratory Evaluation and Treatment 7 that are carrying oxygen. In general. because patients need to use oxygen for a significant portion of each day and because it can lead to additional difficulties in mobility. leading to the damage of healthy tissues. Oxygen therapy is contraindicated in patients undergoing treatment with certain forms of chemotherapy. such as with the drug bleomycin. which can lead to tissue dysfunction and cell death. Excess oxygen flow also can result in conditions such as barotrauma. a chronic disorder affecting infants. For example.
Likewise. Furthermore. they may cause explosions. or other sources of ignition. oxygen can readily spread fire. suffocation. can prevent some deaths from drowning. throat. exchanging air and carbon dioxide in the terminal air sacs of the lungs while the heart is still functioning. strangulation. The person using mouth-to-mouth breathing places the victim on his back. 218 . which has been found to be more effective than the manual methods used in the past.7 The Respiratory System 7 properly. places his own mouth over the victim’s mouth in such a way as to establish a leak-proof seal. and electric shock. Such techniques. To be successful such efforts must be started as soon as possible and continued until the victim is again breathing. Resuscitation by inducing artificial respiration consists chiefly of two actions: 1. and thus there is a significant safety hazard associated with the use of oxygen in the presence of pilot lights. if applied quickly and properly. carbon monoxide poisoning. The most widely used method of inducing artificial respiration is mouth-to-mouth breathing. candles. clears his mouth of foreign material and mucus. Artificial Respiration Artificial respiration is breathing induced by some manipulative technique when natural respiration has ceased or is faltering. and pharynx) to the lungs and 2. the prescription of oxygen for patients who smoke or who share a household with smokers is considered controversial. lifts the lower jaw forward and upward to open the air passage. establishing and maintaining an open air passage from the upper respiratory tract (mouth. choking.
Stockbyte/Getty Images 219 .7 Approaches to Respiratory Evaluation and Treatment 7 Mouth-to-mouth breathing is the most effective means of manual artificial respiration.
the rescuer may cover both the victim’s mouth and nose. including the lungs. including pleural empyema. the results of chest percussion and imaging tests. If the victim is a child. permitting the victim to exhale. particles such 220 . The rescuer breathes 12 times each minute (15 times for a child and 20 for an infant) into the victim’s mouth. as well as to prevent further complications associated with the condition. tumours. Thoracentesis Thoracentesis is a medical procedure used in the diagnosis and treatment of conditions affecting the pleural space. Thoracentesis is used therapeutically to relieve the symptoms associated with pleural effusion.7 The Respiratory System 7 and clamps the nostrils. such as tuberculosis and pneumonia. such as chest X-rays or computerized axial tomography chest scans. a needle is inserted through the chest wall and into the effusion site in the pleural space. are assessed to precisely locate the site of fluid accumulation and to evaluate the volume of fluid present. fluid is drawn out of the pleural cavity using a syringe or other aspiration technique. He then alternately breathes into the victim’s mouth and lifts his own mouth away. Needle placement is sometimes guided by ultrasound to avoid puncturing nearby tissues. Pleural effusion can result in difficulty in breathing and often occurs secondary to conditions that affect the heart or lungs. In the subsequent thoracentesis procedure. and lung infections. including infectious organisms. Prior to thoracentesis. It is most often used to diagnose the cause of pleural effusion. Once the needle is inserted. including heart failure. and spleen. the abnormal accumulation of fluid in the pleural space. liver. a small amount of fluid is drawn and then analyzed for the presence of a variety of substances. For diagnostic applications.
gas gangrene resulting from infection by anaerobic bacteria. generally lasting about 10 to 15 minutes. Experimental compression chambers first came into use around 1860. 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. carbon monoxide poisoning. the accumulation of air in the pleural space.7 Approaches to Respiratory Evaluation and Treatment 7 as asbestos. which are suggestive of mesothelioma or lung cancer. Hyperbaric Chamber A hyperbaric chamber. is a sealed chamber in which a high-pressure environment is used primarily to treat decompression sickness. which occurs when a needle punctures the lungs.e. and tumour cells. Thoracentesis is contraindicated in persons with bleeding disorders (i. and wounds that are difficult to heal. gas embolism. tissue injury arising from radiation therapy for cancer. The results of these analyses frequently warrant further diagnostic testing. also known as a decompression chamber (or recompression chamber). and aberrant stimulation of the vasovagal reaction. leading to a drop in blood pressure and fainting (syncope). Air. Thoracentesis is a relatively quick procedure. particularly upon detection of cancerous cells.. a reflex of the nervous system that causes heart rate to slow (bradycardia) and blood vessels in the lower extremities to dilate. In its simplest form. Minor complications associated with thoracentesis include pain and cough. another breathing mixture. More serious complications include pneumothorax. or oxygen is pumped in by a compressor or allowed to enter from pressurized tanks. for several hours afterward patients are often observed for the manifestation of adverse effects. Pressures 221 . coagulopathy). However.
or from a combination of the two. Chris McGrath/ Getty Images used for medical treatment are usually 1.5 to 3 times higher than ordinary atmospheric pressure. 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.7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). In the treatment of decompression sickness. for example. 222 . a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. In the treatment of carbon monoxide poisoning.
who may be relatively young. often have also suffered lung injury or lung infection. Many recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. Persons severely disabled by cystic fibrosis. sarcoidosis. for example. 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. the techniques are being pursued aggressively in specialized centres.7 Approaches to Respiratory Evaluation and Treatment 7 Lung Transplantation Early attempts at transplanting a single lung in patients with severe bilateral lung disease were not successful. Availability of donor lungs is sharply limited by the number of suitable donors. pulmonary fibrosis. conclusion In the 21st century. With proper selection of donor organs and proper transplantation technique. Because transplantation offers the only hope for persons with severe lung disease. respiratory medicine has continued to fulfill a vital role in advancing scientists’ understanding of respiratory disease and of the basic cellular and molecular processes that contribute to the normal function of the 223 . many people who die of severe head injuries. which presumably would leave the lungs intact. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. emphysema. survival at one year has been reported at 90 percent. but from the late 1970s bilateral lung transplantation had some striking results.
Such progress promises to reduce the global mortality of lung cancer.7 The Respiratory System 7 respiratory system. and this understanding has contributed to a more complete realization of the importance of prevention and early detection of diseases such as lung cancer. countries worldwide have initiated national and international programs aimed at reducing human exposure to pollutants. Significant advances also have occurred concerning scientists’ understanding of the genetic causes of respiratory disorders and of the agents responsible for infectious respiratory diseases. In many countries. these efforts have led to smoking bans in public areas and to governmental regulations limiting occupational exposure to irritants. 224 . in 2009 researchers reported having mapped the genetic codes of rhinoviruses. For decades. The genetic information was being used to establish an understanding of the relationships between the dozens of common-cold rhinoviruses and was expected to provide new insights that could potentially lead to the development of diagnostic tests and possibly even new drugs or vaccines. The influenza virus that produced the H1N1 pandemic of 2009 is at the centre of these ongoing investigations. acquiring genetic mutations that alter their infectious characteristics. The importance of understanding the evolutionary patterns of respiratory viruses is perhaps best illustrated by the various types of influenza virus. mesothelioma. and similar preventable respiratory afflictions. sometimes drastically increasing their ability to infect and cause disease in humans. The negative influence of behaviours such as tobacco smoking on lung function is now well documented. basic knowledge of the viruses that cause the common cold eluded scientists. with health and environmental concerns at the forefront. Influenza viruses circulate globally. However. which are the most frequent cause of the common cold. In fact.
7 Approaches to Respiratory Evaluation and Treatment 7 Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease. For example. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. 225 . As researchers and physicians continue to uncover new information about the human respiratory system. In addition. as well as new treatments. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. 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.
hyperbaric chamber A sealed chamber in which a highpressure environment is used for medical treatment. cricoid A large cartilaginous piece of the laryngeal skeleton with a signet-ring shape. hypoventilation When the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange. functions as a lid to the larynx and. hypercapnia Excess carbon dioxide retention. extrinsic muscles Join the laryngeal skeleton cranially to the hyoid bone or to the pharynx and caudally to the sternum. convection The transfer of heat by movement of a heated fluid such as air or water. moving it upward or downward. Act on the larynx as a whole. epiglottis Cartilaginous. diffusion Primary mode of transport of gases between air and blood in the lungs and between blood and respiring tissues in the body. during the act of swallowing. or transformation of glucose into energy. glycolysis Fermentation. leaf-shaped flap. Also known as a decompression chamber or recompression chamber. controls the traffic of air and food. glottis A sagittal slit formed by the vocal cords. hyperventilation Form of overbreathing that increases the amount of air entering the pulmonary alveoli. 226 .GLOSSARY apnea Cessation of breathing.
sinusitis Acute or chronic inflammation of the mucosal lining of one or more paranasal sinuses. reduces its surface tension. intrinsic muscles Attach to the skeletal components of the larynx and act directly or indirectly on the shape. when added to a liquid. pleura In humans. larynx A complex organ that serves as an air canal to the lungs and a controller of its access. resulting in the development of secondary tumours. a thin membranous sac encasing each lung. pleural effusion Accumulation of watery fluid between the membrane lining the thoracic cage and the membrane covering the lung. purulent Pus-producing. pharyngitis Painful inflammatory illness of the passage from the mouth to the pharynx or of the pharynx itself. length. nasopharynx Primarily a passageway for air and secretions from the nose to the oral pharynx. rhinitis Inflammation of the mucous tissue of the nose. 227 . metastasis Migration and spread of cancerous cells from a tumour to distant sites in the body. neuraminidase A glycoprotein on the surface of influenza viruses. thrombus Clot that forms in the blood vessel and remains at the point where it was formed.7 Glossary 7 hypoxia Reduction of oxygen supply to tissues to less than physiological levels. and as the organ of phonation. thereby increasing its spreading and wetting properties. and tension of the vocal cords. paranasal sinuses Cavities in the bones that adjoin the nose. surfactant Substance that.
Altose and Yoshikazu Kawakami (eds. Peter T. Sullivan (eds. (1994). 2nd ed.). Fishman’s Pulmonary Diseases and Disorders. ed. Berger. 2nd ed.). Physiology of Respiration. HighAltitude Medicine and Pathology. (1995). H. Hlastala and Albert J. (2008). and Jerome A. 1 also available in a 3rd ed. Respiratory Function in Disease: An Introduction to the Integrated Study of the Lung. 228 . (1971). Diagnosis of Diseases of the Chest. Fishman and Jack A. Sleep and Breathing.. and Ronald V. 4th ed. 4 vol. (1995). 4th ed. 2nd ed. (2001). and Michael P. Pack (eds. (1993). Comprehensive coverage of the diseases of the human respiratory system is provided by Alfred P. Abnormal breathing during sleep is covered by Nicholas A. Regulation of Breathing. (1977–79).BIBLIOGRAPHY Basic information about the respiratory system and the process of respiration is included in Andrew Davies and Carl Moores. The Respiratory System (2003). a detailed text on impairment of lung function caused by disease. Dempsey and Allan I. and Robert G.). Saunders and Colin E. 2nd ed. Elias. Bennett and David H. (1988).. 2nd. Elliott (eds. Control of Breathing in Health and Disease (1999). Macklem. The Physiology and Medicine of Diving. Corwin Hinshaw and John F. The human respiratory system is described in David V. Control of breathing is described in Murray D. The effects of swimming and diving on respiration are detailed in Peter B. Bates. Christie. Murray. 4th ed. Adaptations of the human respiratory system to high altitude are described in a comprehensive but readable manner in Donald Heath and David Reid Williams. Fraser et al.). with vol.
Thurlbeck’s Pathology of the Lung. Principles of Pulmonary Medicine.. 4th ed. and Ian R. Fishman (ed. (1981). Weinberger. 2nd ed. 2nd ed. Comprehensive texts include Gordon Cumming and Stephen J. provides a comprehensive overview of pathophysiology as related to clinical syndromes. 229 . is a general textbook covering diagnosis and treatment of chest diseases. Semple. (eds.).). John Crofton and Andrew Douglas. Pulmonary Diseases and Disorders.). Scientific Foundations of Respiratory Medicine (1981). Cameron and Nigel T. G. Churg et al. 3rd ed. Murray and Jay A.). (1998). (1980). (1980). Nadel (eds. 3 vol. and Andrew M. (1994). 3rd ed. Disorders of the Respiratory System. (2005).7 Bibliography 7 Diseases of the Chest. See also John F. is an introductory text in which respiratory pathophysiology is considered from the clinical vantage. Textbook of Respiratory Medicine. Scadding and Gordon Cumming (eds. Respiratory Diseases. 2nd ed. see also J. Alfred P. Steven E. 3rd ed. (1988). Respiratory Disorders (1983). Bateman.
111. 209 animals. 186. 81. 77 Agricola. 198 bronchioles. 176. 197 bronchopulmonary dysplasia. 46. 52. 109. 230 . 159. 99–100. 170–171 Bordet. 187 anesthesia. 137. 115. 92. 91. 30. 184–186 altitude sickness. 64. 122. 118–119 air–blood barrier. 193 anthracosis.INDEX A acid–base balance. 38. 171–173 asphyxiation. 218–220 asbestos. 171. 93. 116. Paul. 51. 152. 111 Adam’s apple. 171 AIDS. 174 Buerger disease. 187 byssinosis. 30. 152. 164. 103. 205–208 brown lung. 188–189 alveoli. 171–173. 46. 129. 169 lung. 197. 210. 39 alcoholism. 211. 127. 173. 126 arterial gas embolism. 110. 188 bird fancier’s lung. 196. 76. structure and function of. 198. 217 Bert. 211. 50 Breuer. 127. 166 black lung. 172. 108. 221 asbestosis. 100–102. 74. 28–29 bronchiectasis. 137. 217 bronchoscopy. 168–169. 175. 81. 124–125. 86. 194 asthma. 147. 184. 112–113. 160–164. 34–35 amantadine. 184 Actinomyces. 123. 30. 212–214 aortic body. Georgius. 114. Josef. 213 atelectasis. 49 bronchi. 182.130–131. 159. 214 antihistamines. 117. 171 antibiotics. 134. 175. 223 bronchitis. 136. 79–80. 35. Jules. 42. structure of. structure and function of. 135. 96. 103 anemia. 131. structure of. 111. 75. 168. 75 acidosis. 169. 181. 169. 131–133. 73. 153. 169. 85 artificial respiration. 113 alkalosis. 33–34 bronchiolitis. 107. 106 bradykinin. 174–175 C cancer. 189–192. 94. 102. 208. 33–34 stem. 48 apnea. 141–144 B barotrauma. 97. 27 adenosine triphosphate (ATP). 152–156. 52.
John Scott. 221 cardiopulmonary resuscitation (CPR). 168. 63. 64. 159. 106. 47. 158. 157–158. 213 cause of. 81 central nervous system disease. 149. 85. 50. 197–198 H Haldane. 177. 171. 58–59. 196–197. 197. 209. 215. 69. 66. 112. 196. 78. 221. 97. 108. 115. 69–72 Gengou. 145. 184. 216–217 Hering. 132 types of. 183. 25. 190. 56. 52 chloride shift. 156–158. 210. 98–99 epinephrine. 164 coughing blood. 87. 170. 117. 84. 98. 187. 49 high altitudes. 78. 180. 199. 91. 129. Ewald. 214 diving. 87. 191–193 drowning. 25. 46. 137. 74 goblet cells. 175. 27. 187. 215. 111. 222 decongestants. 80. 223 eosinophilic granuloma. 190 histamine. 95. 122. 161. 81–86. 80. 93. 72 diphtheria. 102. 158 diffusion limitation. 192. 131. 130. 122. 207 physiology of. 156. 94. 65. 30. 84. 183. 136–138. 183 hay fever. 98–99 epiglottitis. 88–91. 50. 182 G gas exchange. 50. 213 hemoglobin. 64. 211–212 diaphragm. 47. 150 epiglottis. 137. 197. 133–136. 186. 201 F farmer’s lung. 75. 136. 164. 75–78. 52 Cheyne-Stokes breathing. 135. 51–52. 132. 143. 49 Hering-Breuer reflex. 217 Clara cells. 188–189.7 Index 181. common. 79–81. 212 exercise (training). 88 corticosteroids. 160 HIV. 21. 44. 145–148. 218 dyspnea. 105–106. 95. 122. 106. 220. abnormal. 67. 166 fungi. 65. 30 Goodpasture syndrome. 106 glycolysis. 223 7 E emphysema. 182. 198. 138. 174. 151 D decompression sickness. 98. 201. 198 croup. 204. 48. 130. 130. 94. 215 carotid body. 86. 92. 96. 137. 147. 127–129. 81. 193–195. 189–192. 119 231 . 159. Octave. 67 chronic obstructive pulmonary disease (COPD). 98–99 cystic fibrosis. 47. 190. 34 cold. 144. 62. 98. 211. 60.
147. 47. 76–77. 46–48. 138. 127 hygiene. 126 hypoxemia. 159 congestion of. 209. 172. 87. 110. 150. 198. 99 mediastinoscopy. 98. 214 leukemia. 38. 221 collapse of. 135–136. 88. 68. 93. 144–145. 141. 139. 223 lung ventilation/perfusion scan. 221–222 hypercapnia. 173. 178. 26–28 Legionnaire disease. 26. 204–205 M measles. 138–141. 103 H1N1. 166–167 hyperventilation. structure and function of. 149. 110. 138. 91. 50. 196 laryngitis. 41. 96.7 The Respiratory System 7 hookworm. 129. 169. 83. 221 metabolism. 197 development of. 113–114. 83 hypersensitivity pneumonitis. 94. 171–173. 74. 92. 184 L Laënnec. 95–96 larynx. 173 cancer of. 31. 37. 81 mountain sickness. 204. 190. 70. 128. 44. 76 Monge disease. 176. 208 medulla. 178. 149. 50 meningitis. 125 hypoventilation. 199. 151. 81 aerobic. 74. 100 lungs N nephritis. 103. 199 bird flu. 156–158. 69. 73–78. 38–40 infarction. 145 K kidney. 114. 198. 152–156. 163 hydrothorax. René-ThéophileHyacinthe. 149 influenza. 31 transplantation of. 167. 217 hypoxia. 99. 104 vaccine. 49. 177 size of. 173. 87. 181. 81 mucoviscidosis. 182. 215. 127. 102–105. 117 mesothelioma. 184–186 hypothyroidism. 94 nerves laryngeal. 52. 122. 45. 26 232 . 208–209 mediastinum. 215. 114–115. 78 anaerobic. 55–56. 127. 119 hyperbaric chamber. 186–188 I idiopathic pulmonary fibrosis. 143. 81–82. 117. 51–52.
93 congestion of. 211. 107–108. 103 Röntgen. 189. 209. 104–105 respiratory distress syndrome. 33. S sarcoidosis. 31–32. 168–169. 179–180 Reynaud disease. 45. 130. structure and function of. 69–71 silicosis. 214. 139. 137 oxygen therapy. 57.7 olfactory. 178. 104 osteoporosis. 89 structure and function of. 128 R Relenza. 198 pleural effusion. 214–218 128. 87. 53. 118 prostaglandins. 138. 126 oseltamivir. 47 vagus. 136. 160 sleep. 103. 173. 220 pleurisy. 164 pharyngitis. 129–130. 200. 150–151 pulmonary edema. 155. 122. 179 rheumatoid arthritis. 94. 211. 159. 194 pulmonary parenchyma. 214 pertussis. 180. 114 Pott disease. 167. 214 pharynx. 170 pneumonia. 198 pneumoconiosis. 198. 91. 91. 131. 22. 126–130. 107 penicillin. 113. 154. 114. 103. 36. 107. 33. 92. 50. 23–24 sinus. 126 pleura. 95. 208. 221 pollution. 108. 110 pulmonary alveolar proteinosis. 44 Pontiac fever. 88 rimantadine. 139. 136 233 . 50 psittacosis. 100 rhinoviruses. 137. 127. 34 pyothorax. 107. 103.Wilhelm Conrad. 22 irrigation of. 164 inflammation of. 126. 111 parrot fever. 184. 106. 91. 172. 126. 87. 92. 93. 169–170 sinuses. 223 scarlet fever. 127–129. 149–150. 19. 99 Index 7 O obesity. 141. 146. 91–92. 108. 180–182 pons. 170. 208. 122 function of. 87. 56. 85 nose cilia. 198. 26. 88. 127. 117. 152. 220 pneumothorax. 84. 125. 203 P parasites. 21–24. 50 nitrogen narcosis. 38. 105–106. 93 sinusitis. 128. 41. 92–94. 24–25 pickwickian syndrome. 52–53. 85. 124. 187 rheumatic fever. 108–113. 95 shunting.
220 typhoid. 27–28 vitamin C. 78. 138. 204. 81–86 syphilis. 92 streptococcal bacteria. 23–24. 172. 97 V vaccination. 118. 122. 199. 218 sneezing. 94–95. 143. 95. 94 staphylococci. 108. 104 tetanus. 91. 97. 173 Valsalva maneuver. 111. 128. 192–193 tonsillitis. 105–107 Z zanamivir. 96. 133–135. 138. 123. 96–98 trench mouth. 197. 96. 130. 99. 163. 27–28 T Tamiflu. 69 vestibular folds. 178. 171. 106 thoracentesis. 214 surgery. 138. 175. 103. 94. 123–124 sore throat. 93. 93. 122. 97. 109. 97 trachea. 124 W whooping cough. 21. 94 smoking. 183. 106. 130. 107. 153. 131–132. 91 vocal chords. 164. 110. 58 ventilation–blood flow imbalance. 87. 150. 136. 92. 182. 91. 53. 152. 95. 137. 146 strep throat. 125. 25. 97. 116. 170. 88. 53. 95. 129. 91. 198.102. false. 92. 97 smell. 28–30 tracheitis. 164 snoring. 164.7 The Respiratory System 7 smallpox. 104–105 234 . 208. 103. 56. 33. 92. 95 tuberculosis. 155–156. 220–221 thoracic emphyema. 92. 199. 87. 209 swimming. 99. 94–95 tonsils. structure and function of. 103. 102. 127–129 thoracic squeeze. 119. 171. 176. 97. 114–121. 92. 87.
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