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

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

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

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

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

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

INTRODUCTION .

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

A series of neural networks in the brain control the rate of breathing by communicating with the muscles in the chest and the 12 . and to the left atrium of the heart. the pulmonary system. is an automatic process. comprises the network of blood vessels supporting the conducting airways themselves. Lungs also have two distinct blood circulation systems. humans and other animals do not need to actively think about breathing in order for it to happen. The average adult lung has approximately 300 million alveoli. The second blood system in the lungs. through the pulmonary veins. which look like cells in a honeycomb. the region where oxygen is transferred to the blood and carbon dioxide is removed. which range in diameter from 3 mm (0.12 inch) to less than 1 mm (less than 0. which makes exchanging gases easier. and to the lungs and by the subsequent transport of oxygen-rich blood from the lungs. Thus.7 The Respiratory System 7 bronchioles. The exchange of carbon dioxide and oxygen takes place in tiny air sacs called alveoli. controlled by the brain. From the heart. through the pulmonary arteries. air. The tissue compartment supports the air and blood compartments and lets them come into close contact. the oxygenated blood is pumped to the rest of the body. is characterized by the transport of carbon dioxide–laden blood from the right side of the heart. The act of breathing.04 inch). thereby delivering oxygen and other nutrients to organs distant from the lungs. or respiration. but still keeps them separate. the bronchial circulation. is made up of three separate compartments for blood. The first of these. The gas-exchange area. and tissue. The bronchial circulation is a vital source of nourishment for the lung tissues. A significant feature of the human respiratory system is its capacity to instantly adjust to internal and external stimuli on its own.

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

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

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

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

lung cancer is the leading cause of cancer deaths worldwide. Breathing asbestos can also cause the cancerous condition known as mesothelioma. and even cockroaches. In the early 20th century. it was still considered rare. There is hope for those who suffer from respiratory diseases and disorders. Antiviral drugs capable of treating viral respiratory infections have emerged and become widely available. In addition to vaccines and antivirals. The antiviral agents Tamiflu (oseltamivir) and Relenza (zanamivir) played an important role in treating persons affected by influenza during the H1N1 influenza pandemic of 2009.3 million fatalities each year. Several vaccines have been developed to prevent illnesses such as influenza. however. Scientists are constantly researching and developing new and different treatments for respiratory ailments. resulting in an estimated 1. which affects coal miners who inhale coal dust for many years. Now. Today. most likely resulting from exposure to air pollution. have been around for years and are readily available. antibiotics are vitally important for the treatment of respiratory infections that are caused by bacteria. tobacco smoke. or white lung disease. particularly pneumonia and tuberculosis. factors. Construction workers and insulators exposed to asbestos often suffer from asbestosis.7 Introduction 7 variety of factors. although tobacco smoking is the primary cause. more than 7 percent of children and 9 percent of adults suffer from asthma. or work. Doctors first described the symptoms of lung cancer in the mid-19th century. Some respiratory diseases arise as a result of occupational. however. Breathing problems caused by allergies to environmental conditions are fairly common. Many treatments. 17 . Nasal decongestants and antihistamines are examples of commonly used remedies. The best-known occupational lung disease is black lung.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

T

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

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

which supply the diaphragm and other thoracic and abdominal muscles. allowing the activity of these physiological systems to be coordinated with respiration. The inspiratory and expiratory medullary neurons also receive input from nerve cells responsible for cardiovascular and temperature regulation. 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. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla.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 . Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. Neurally. An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath.

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

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

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

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

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

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

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

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

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

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

A lung is similar to a balloon in that it resists stretch. 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. thereby allowing the lung to separate from the chest at this particular spot. This. 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. is the sequence of events during each normal respiratory cycle: lung volume change leading to pressure difference. therefore. 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. tending to collapse almost totally unless held inflated by a pressure difference between its inside and outside. resulting in flow of air into or out of the lung and establishment of a new lung volume. its pressure rises above atmospheric pressure. and flow into the atmosphere results until pressure equilibrium is reached at the original lung volume. lung air becomes transiently compressed. of the force required to keep the lung distended.7 Control and Mechanics of Breathing 7 decreases. In summary. the pleural pressure reflects primarily two forces: 55 . The force increases (pleural pressure becomes more negative) as the lung is stretched and its volume increases during inspiration. then. This negative (below-atmospheric) pressure is a measure. 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.

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

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

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

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

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

com 61 .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. Shutterstock.

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

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

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

with the red blood cells containing considerably less bicarbonate and more carbamate than the plasma. The distribution of these chemical species between the interior of the red blood cell and the surrounding plasma varies greatly. blood normally remains in the pulmonary capillaries less than a second. principally hemoglobin.7 Gas Exchange and Respiratory Adaptation 7 to the left. to form a compound known as carbamate. remains unchanged and is transported dissolved in blood. whereas a decrease in temperature shifts the curve to the left (increased affinity). transport of carbon dioxide Transport of carbon dioxide in the blood is considerably more complex. Temperature changes affect the oxygen-dissociation curve similarly. as occurs at extreme altitude. Furthermore. about 5 percent. About 88 percent of carbon dioxide in the blood is in the form of bicarbonate ion. Some carbon dioxide binds to blood proteins. Complete elimination would lead to large changes in acidity between arterial and venous blood. enhanced release of oxygen). An increase in temperature shifts the curve to the right (decreased affinity. 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. This displacement increases oxygen binding to hemoglobin at any given partial pressure of oxygen and is thought to be beneficial if the availability of oxygen is reduced. The remainder is found in reversible chemical combinations in red blood cells or plasma. Less than 10 percent of the total quantity of carbon dioxide carried in the blood is eliminated during passage through the lungs. 65 .

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

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

because only free carbon dioxide easily crosses biologic membranes. 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. not all inspired air participates in gas exchange. In contrast to the cyclic nature of ventilation. blood flow through the lung is continuous. yet this pool is important. In health.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. Under ideal circumstances. A portion of the inspired breath remains in the conducting airways and does not reach the alveoli where gas exchange occurs. because of the increased size of inspired breaths. most carbon dioxide is transported as bicarbonate or carbamate. and almost all blood entering the lungs participates in gas exchange. gas exchange in the lung The introduction of air into the alveoli allows the removal of carbon dioxide and the addition of oxygen to venous blood. This portion is approximately one-third of each breath at rest but decreases to as little as 10 percent during exercise. Because ventilation is a cyclic phenomenon that occurs through a system of conducting airways. ventilation and blood flow are extremely well matched in each exchange unit throughout the lungs. Between these two events. Normally there is a small difference between oxygen tensions in alveolar gas and arterial blood because of the effect of 68 . partial pressures of oxygen and carbon dioxide in alveolar gas and arterial blood are identical. The efficiency of gas exchange is critically dependent on the uniform distribution of blood flow and inspired air throughout the lungs.

. but the level of carbon dioxide in arterial blood is not elevated even 69 . Mechanisms of abnormal gas exchange are grouped into four categories: hypoventilation. alveoli filled with fluid or inflammatory material). If the quantity of inspired air entering the lungs is less than is needed to maintain normal exchange—a condition known as hypoventilation—the alveolar partial pressure of carbon dioxide rises and the partial pressure of oxygen falls almost reciprocally. shunting. A reduction in arterial blood oxygenation is seen with shunting. In shunting. Because of the differences in oxygen and carbon dioxide transport. and limitations of diffusion. Shunting of blood may result from abnormal vascular (blood vessel) communications or from blood flowing through unventilated portions of the lung (e. 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. venous blood enters the bloodstream without passing through functioning lung tissue. These events have no measurable effect on carbon dioxide partial pressures because the difference between arterial and venous blood is so small. ventilation– blood flow imbalance. abnorMal gas exchange Lung disease can lead to severe abnormalities in blood gas composition. Similar changes occur in arterial blood partial pressures because the composition of alveolar gas determines gas partial pressures in blood perfusing the lungs.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. impaired oxygen exchange is far more common than impaired carbon dioxide exchange.g.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

At the extreme depths now attainable by humans— some 500 metres (1. Oxygen in excess can be a poison. provides a greater respiratory advantage for deep diving. it may cause the rapid onset of convulsions. has the additional advantage of providing a breathing gas of lesser density. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. 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. In mixed-gas diving. which in a mixture with less than 4 percent oxygen is noncombustible. At a partial pressure greater than 1.230 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. like an anesthetic.5 bar.640 feet) in the sea and more than 680 metres (2. The use of hydrogen. High values of end-tidal carbon dioxide with 84 .5 bar (“surface equivalent value” = 150 percent). Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic. approximately in proportion to the reciprocal of the square root of the increasing gas density.2 and 0. An ability to tolerate carbon dioxide may increase the work capacity of a diver at depth but also may predispose him to other consequences that are less desirable. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. inspired oxygen is therefore maintained at a partial pressure somewhere between 0.7 The Respiratory System 7 increased.

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

Inadequacy of diver decompression.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.6 feet). 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. 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. which may occur as a result of the diver’s failure to follow a correct decompression protocol or occasionally as a result of a diver’s idiosyncratic response to an apparently safe decompression procedure. 86 . can result in a sometimes life-threatening condition known as decompression sickness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A tubercle usually consists of a centre of dead cells and tissues. In otherwise healthy children and adults. in which can be found many bacilli. 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. There the bacilli become trapped in the tissues of the body. The Course of Tuberculosis The tubercle bacillus is a small. and even talking can contain hundreds of tubercle bacilli that may be inhaled by a healthy person. sometimes involving the use of five different agents. and a small scar in the lung may be visible by X-ray. coughing. are surrounded by immune cells. but most of the visible manifestations of tuberculosis. nodular tubercles. are conglomerations of tubercles. from barely visible nodules to large tuberculous masses. sometimes called latent 116 . Infection spreads primarily by the respiratory route directly from an infected person who discharges live bacilli into the air. A skin test taken at any later time may reveal the earlier infection and the immunity. Infections with these strains are often difficult to treat and require the use of combination drug therapies.7 The Respiratory System 7 rise of new strains of the tubercle bacillus that are resistant to conventional antibiotics. and finally are sealed up in hard. The tubercle thus forms as a result of the body’s defensive reaction to the bacilli. rod-shaped bacterium that is extremely hardy. In this condition. and the infected person acquires a lifelong immunity to the disease. Minute droplets ejected by sneezing. cheeselike (caseous) in appearance. Individual tubercles are microscopic in size. The bacilli are quickly sequestered in the tissues. This centre is surrounded by radially arranged phagocytic (scavenger) cells and a periphery containing connective tissue cells.

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

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

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

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

In addition. Although some patients consider DOT invasive. has been shown to be effective in reducing mortality in roughly 50 percent of XDR TB patients.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. it has proved successful in controlling tuberculosis. which are selected based on the drug sensitivity of the specific strain of bacilli in a patient. amikacin. or capreomycin. typically requiring two years of treatment with agents known to have more severe side effects than isoniazid or rifampicin. Instead of taking daily medication on their own. In 1995. XDR TB is characterized by resistance to not only isoniazid and rifampin but also a group of bactericidal drugs known as fluoroquinolones and at least one aminoglycoside antibiotic. Aggressive treatment using five different drugs. patients are directly observed by a clinician or responsible family member while taking larger doses twice a week. aggressive treatment can help prevent the spread of strains of XDR TB bacilli. such as kanamycin. in part to prevent the development and spread of MDR TB. Extensively drugresistant tuberculosis (XDR TB) is a rare form of MDR TB. the World Health Organization began encouraging countries to implement a compliance program called directly observed therapy (DOT). 121 . MDR TB is treatable but is extremely difficult to cure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

welders. the tumour’s type and degree of invasiveness are determined. small-cell 153 . and roofers. Of the two basic forms. Tumours can begin anywhere in the lung. and susceptibility to lower respiratory infections. smokers exposed to these substances run a greater risk of developing lung cancer than do nonsmokers. or bone pain may occur. The most common symptoms include shortness of breath. chest pain. Heavy smokers have a greater likelihood of developing the disease than do light smokers. bloody sputum. Types of Lung Cancer Once diagnosed.7 Diseases and Disorders of the Respiratory System 7 Causes and Symptoms Lung cancer occurs primarily in persons between ages 45 and 75. Lung cancer is rarely caused directly by inherited mutations. The risk is also greater for those who started smoking at a young age. visible lumps. Uranium and pitchblende miners. between 80 and 90 percent of all cases are caused by smoking. jaundice. such as coal processors. According to the American Cancer Society. a persistent cough or wheeze. Passive inhalation of cigarette smoke (sometimes called secondhand smoke) is linked to lung cancer in nonsmokers. Other risk factors include exposure to radon gas and asbestos. In cases where the cancer has spread beyond the lungs. and workers exposed to halogenated ethers also have an increased incidence. In countries with a prolonged history of cigarette smoking. as do some workers in hydrocarbon-related processing. secondhand smoke accounts for an estimated 3.400 deaths from lung cancer in nonsmoking adults in the United States each year. but symptoms do not usually appear until the disease has reached an advanced stage or spread to another part of the body. unexplained weight loss. tar refiners. chromium and nickel refiners.

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

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

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

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

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

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

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

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

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

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

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

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. Ragweed pollen is typically dispersed in the air from late summer to mid-fall in many areas of central and eastern North America. Louise K.

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

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. 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. occupational lung disease Occupational lung diseases are caused by the inhalation of a variety of organic or inorganic dusts or chemical 167 . but sometimes the precise agent cannot be identified. or in response to a variety of other agents. An influenza-like illness resulting from exposure to molds growing in humidifier systems in office buildings (“humidifier fever”) has been well documented. Runk/Schoenberger from Grant Heilman exposure to redwood sawdust. It is occasionally attributable to Aspergillus.

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

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

In the past a large proportion of sufferers of silicosis died of tuberculosis. cannot be digested by the macrophages and instead kill them. Lung volume is reduced. These symptoms are all related to a fibrosis that reduces the elasticity of the lung. is a respiratory disorder caused by repeated inhalation of 170 . The killed cells accumulate and form nodules of fibrous tissue that gradually enlarge to form fibrotic masses.7 The Respiratory System 7 disease rarely occurs with exposures to concentrations of less than 6. however. emphysema. also known as coal-worker’s pneumoconiosis. called macrophages. In the actual disease process. and gas exchange is poor. since there is no effective treatment. Silica particles. and the abdominal lymph nodes. and particles of one to three microns do the most damage.0004 inch) in diameter penetrate to the finer air passages of the lungs. Silicosis predisposes a person to tuberculosis. that serve to protect the body from bacterial invasion. the tiny particles of inhaled silica are taken up in the lungs by scavenger cells. and. control of the disease lies mainly in prevention. and weakness. 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. difficulty in breathing. the openings to the lungs. and pneumonia. Only very small silica particles less than 10 microns (0. The symptoms of silicosis are shortness of breath that is followed by coughing. There is no cure for silicosis.000 particles of silica per cubic foot (about 210.000 per litre) of air. though this has changed with the availability of drug therapies for that disease. Black Lung Black lung. These whorls of fibrous tissue may spread to involve the area around the heart.000.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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). the subject feels dizzy and is unable to perform simple tasks. For this reason. leaving only 60 percent available to bind to oxygen). and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. 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. Carbon monoxide is produced by incomplete combustion. Judgment is also impaired. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. including combustion of gas in automobile engines. 183 . as part of his detailed analysis of atmospheres in underground mines. 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. a condition in which hemoglobin is deficient. When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide.7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. 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. 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.

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

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

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

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

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

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

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

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

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

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

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

Actual arrest of circulatory processes is a relatively late development in the drowning sequence. Scientists have determined that vestiges of the reflex persist in humans. enhances survival during submersion. the volume of fluid entering the lungs rarely exceeds a glassful. known as the mammalian diving reflex. It also causes an interruption of respiratory efforts and reduces the rate of the heartbeat. When aspiration does occur. Up to 15 percent of drownings are “dry. The lungs “fill with water” chiefly because of an abnormal accumulation of body fluids (pulmonary edema) that is a secondary complication of oxygen deprivation. thus permitting seagoing mammals to hunt for long periods underwater.” presumably because the breath is held or because a reflex spasm of the larynx seals off the airway inlet at the throat. in other respects it performs normally. intracranial blood retains sufficient oxygen to meet the brain’s reduced metabolic needs. In this suspended state. Vomiting after the protective laryngeal spasm has subsided can lead to aspiration of stomach contents. The mechanism is powerful in children. Often. abdomen. Even though the heart functions at a slower rate. despite a total absence of respiratory gas exchange.7 The Respiratory System 7 body’s physiological defenses against drowning has prompted modification of traditional therapies and intensification of resuscitative efforts. 194 . and surface areas of the body to the heart and the brain. 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. It diverts blood from the limbs. A natural biological mechanism that is triggered by contact with extremely cold water. Although asphyxiation (lack of oxygen that causes unconsciousness) is common to all immersion incidents. so that many people who once would have been given up for dead are being saved.

and promotes unconsciousness. 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.” “Lifeless” immersion victims with core temperatures as low as 62. so the oxygen deprivation caused by immersion is rapidly lethal or permanently damaging to the brain. slows the heart rate. Immersion hypothermia—below normal body temperature—reduces cellular activity of tissues. Immersion in icy water causes body temperature and metabolism to fall rapidly (the thermal conductivity of water is 32 times greater than that of air). None of these effects is imminently life-threatening. 195 .6 °F (17 °C) have survived. Such warmwater drownings occur commonly in domestic bathtubs. survival following hypothermic coma is almost 75 percent.

Likewise. One of the most important advances in the history of respiratory medicine was the development of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. Today. have contributed to improvements in the diagnosis and evaluation of respiratory disease. particularly concerning techniques employing X-ray imaging or endoscopy. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. physiology. and pathology of the human respiratory system is known as pulmonology. T recognizing the signs and syMptoMs of disease The symptoms of lung disease are relatively few. In addition. 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. or respiratory medicine. modern respiratory medicine is intimately associated with ongoing scientific research into the cellular and molecular processes that underlie respiratory function. many technological advances. especially in the area of disease prevention. A cough productive of sputum is the most important manifestation of inflammatory or 196 . This expansion of scientific understanding has enabled important progress in respiratory medicine.CHAPTER7 APPROACHES TO RESPIRATORY EVALUATION AND TREATMENT he study of the anatomy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

or from a combination of the two. a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues. for example. Chris McGrath/ Getty Images used for medical treatment are usually 1.5 to 3 times higher than ordinary atmospheric pressure. In the treatment of decompression sickness. which increases oxygen availability to the body in therapeutic treatment.7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. In the treatment of carbon monoxide poisoning. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. 222 .

the techniques are being pursued aggressively in specialized centres. or severe primary pulmonary hypertension can achieve nearly normal lung function several months after the procedure. who may be relatively young. Availability of donor lungs is sharply limited by the number of suitable donors. but from the late 1970s bilateral lung transplantation had some striking results. emphysema. survival at one year has been reported at 90 percent. Persons severely disabled by cystic fibrosis. This complication is thought to represent gradual immunologic rejection of the transplanted tissue despite the use of immunosuppressant drugs. Brochiolitis obliterans and the constant risk of serious infection brought about by the use of immunosuppressant drugs limit survival to approximately 40 to 60 percent five years after surgery. many people who die of severe head injuries. 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 recipients of single or double lung transplantation develop bronchiolitis obliterans beginning several months or years after surgery. pulmonary fibrosis. conclusion In the 21st century. Because transplantation offers the only hope for persons with severe lung disease. With proper selection of donor organs and proper transplantation technique.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. for example. which presumably would leave the lungs intact. often have also suffered lung injury or lung infection. sarcoidosis.

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

In addition. discoveries of cellular proteins that are involved in cancer and that facilitate the transport of infectious agents into cells have spurred the development of drugs designed to inhibit these pathological activities. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. For example. 225 . the identification of disease-associated metabolic changes within cells and tissues has played an important role in the development of various functional and diagnostic tests.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. As researchers and physicians continue to uncover new information about the human respiratory system. these tests are likely to undergo a series of refinements and to be augmented by the development of new tests. as well as new treatments.

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

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

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

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

169. 112–113.130–131. 111. 153. 211. 152–156. 75 acidosis. 221 asbestosis. 187 byssinosis. 169. 50 Breuer. 175. 131. 111 Adam’s apple. 126 arterial gas embolism. Paul. 184–186 altitude sickness. 85 artificial respiration. 168–169. 122. 170–171 Bordet. 193 anthracosis. 129. structure and function of. structure of. 124–125. 184. 52. 46. Josef. 96. 194 asthma. 223 bronchitis. 135. 159. 181. Jules. 35. 213 atelectasis. 39 alcoholism. 81. 30. 171. 137. 189–192. 188–189 alveoli. 188 bird fancier’s lung. 38. 197. 34–35 amantadine. 77 Agricola. 86. 166 black lung. 205–208 brown lung. 198 bronchioles. 160–164. 159. 171 antibiotics. 115. 152. 169 lung. 230 . 173. 184 Actinomyces. 141–144 B barotrauma. 113 alkalosis. 209 animals. 111. 214 antihistamines. 211. 100–102. 81. 212–214 aortic body. 152. 46. 127. 79–80. 64. 147. 174 Buerger disease. 208. 76. 176. 99–100. 106 bradykinin. structure and function of. 197 bronchopulmonary dysplasia. 42. 169. 103 anemia. 171 AIDS. 217 Bert. 49 bronchi. 118–119 air–blood barrier. 51. 97. 30. 131–133. 174–175 C cancer. 48 apnea. 33–34 stem. 28–29 bronchiectasis. 171–173 asphyxiation. 114. 94. 172. 218–220 asbestos. 182. 103. 109. 137. 107. 27 adenosine triphosphate (ATP). 217 bronchoscopy. Georgius. 33–34 bronchiolitis. 30. 175. 136. 123. 196. 52. 75. 210. 168. 134. 92. 108. 102. 198. 93. structure of. 127. 73. 116. 74. 164. 187 anesthesia. 110. 186. 91.INDEX A acid–base balance. 171–173. 117.

183 hay fever. 136. 75. 98–99 epinephrine. 156–158. 147. 74 goblet cells. 190. 34 cold. 131. 130. 189–192. 174. 119 231 . 94. 112. 117. 102. 63. 196–197. 216–217 Hering. 209. 177. 47. 79–81. 105–106. 88 corticosteroids. 161. 21. 75–78. 81 central nervous system disease. 158 diffusion limitation. 175. 197–198 H Haldane. abnormal. 81. 190 histamine. 211–212 diaphragm. 212 exercise (training). 136–138. 106 glycolysis. 78. 51–52. 218 dyspnea. 64. 122. 62. 157–158. 199. 47. 168. 207 physiology of. 223 eosinophilic granuloma. 164 coughing blood. 25. 211. 201 F farmer’s lung. 188–189. 64. 98–99 cystic fibrosis. 193–195. 98. 108. 67 chronic obstructive pulmonary disease (COPD). 85. 182. 183. 223 7 E emphysema. 80. 27. 115. 84. John Scott. 215 carotid body. 91. 122. 132. 143. 159. 145–148. 44. 182 G gas exchange. 130. 80. 201. 95. 192. 197. 166 fungi. 87. 127–129. 183. 122. 213 cause of. 96. 197. 214 diving. 137. 220. 98. 129. 144. 65. 184. 204. 92. 50. 158. 72 diphtheria. 170. 217 Clara cells. 106. 60. 138. 221 cardiopulmonary resuscitation (CPR). 132 types of. 215. 50. 186. 65. 93. 86. 190. 213 hemoglobin. 49 Hering-Breuer reflex. 30 Goodpasture syndrome. 221. 56. 66. 156. 151 D decompression sickness. 87. 47. 215.7 Index 181. 98. 88–91. 164. 196. 160 HIV. 198. 187. 25. 137. 52 Cheyne-Stokes breathing. 135. 150 epiglottis. 81–86. 97. 159. 52 chloride shift. 94. 78. 180. 69–72 Gengou. 48. 149. 191–193 drowning. 84. 30. 98–99 epiglottitis. 130. 187. 106. 49 high altitudes. 198 croup. 111. 58–59. Ewald. 95. common. 145. 67. 210. Octave. 133–136. 171. 46. 137. 69. 222 decongestants. 50.

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

126. 33. 88 rimantadine. 198. 89 structure and function of. 122 function of. 114 Pott disease. 203 P parasites. 178. 107–108. 170 pneumonia. 149–150. 200. 164 inflammation of. structure and function of. 92. 31–32. 87. 184. 44 Pontiac fever. 189. 129–130. 208. 126 oseltamivir. 211. 125. 87. 220 pneumothorax. 223 scarlet fever. 117. 50 psittacosis. 53. 88. 95. 137 oxygen therapy. 167. 111 parrot fever.Wilhelm Conrad. 85 nose cilia. 22. 164 pharyngitis. 91–92. 85. 127. 93. 214–218 128. 146. 209. 103. 154. 128. 107. 136 233 . 95 shunting. 92. 110 pulmonary alveolar proteinosis. 211. 214. 180. 107. 99 Index 7 O obesity. 104 osteoporosis. 179–180 Reynaud disease. 159. 137. 41. 92–94. 50 nitrogen narcosis. 21–24. 127–129. 194 pulmonary parenchyma. 91. 139. 23–24 sinus. 84. 38. 138. 170. 180–182 pons. 198 pneumoconiosis. 168–169.7 olfactory. 113. 91. 220 pleurisy. 52–53. 126 pleura. 221 pollution. 150–151 pulmonary edema. 187 rheumatic fever. 169–170 sinuses. S sarcoidosis. 106. 22 irrigation of. 124. 24–25 pickwickian syndrome. 198 pleural effusion. 128 R Relenza. 179 rheumatoid arthritis. 104–105 respiratory distress syndrome. 105–106. 57. 127. 94. 93 sinusitis. 108–113. 87. 34 pyothorax. 107 penicillin. 172. 45. 56. 108. 103. 26. 19. 114. 122. 108. 208. 155. 141. 139. 33. 152. 47 vagus. 214 pharynx. 103. 131. 118 prostaglandins. 126. 91. 126–130. 93 congestion of. 103 Röntgen. 130. 136. 50. 36. 173. 214 pertussis. 160 sleep. 198. 69–71 silicosis. 100 rhinoviruses.

103. 92. 110. 198. 197. 118. 58 ventilation–blood flow imbalance. 97. 33. 124 W whooping cough. 94 smoking. 95 tuberculosis. 182. 183. 105–107 Z zanamivir. 173 Valsalva maneuver. 131–132. 199. 93. 171. 97. 171. 27–28 T Tamiflu. 95. 27–28 vitamin C. 164. 92. 94. 163. 96. 146 strep throat. 150. 93. 119. 175. 106 thoracentesis. 208. 94–95 tonsils. 94 staphylococci. 111. structure and function of. 78. 155–156. 123–124 sore throat. 21. 138. 130. 97. 69 vestibular folds. 97 V vaccination. 97 trachea. 56. 99. 91 vocal chords. 81–86 syphilis. 209 swimming. 178. 96–98 trench mouth. 192–193 tonsillitis. 94–95. 23–24. 176. 92 streptococcal bacteria. 218 sneezing. 123.7 The Respiratory System 7 smallpox.102. 91. 28–30 tracheitis. 199. 152. 96. 128. 99. 87. 138. 91. 138. 116. 92. 153. 95. 103. 129. 136. 92. 170. 104 tetanus. 125. 53. 214 surgery. 104–105 234 . 92. 102. 95. 164 snoring. 107. 220 typhoid. 122. 143. 88. 220–221 thoracic emphyema. 103. 87. 122. 137. 97. 109. false. 97 smell. 53. 172. 87. 114–121. 91. 133–135. 108. 106. 127–129 thoracic squeeze. 164. 204. 25. 130.

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