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

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

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 .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Respiratory System

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

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

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

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

T

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

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

An outstanding example of voluntary control is the ability to suspend breathing by holding one’s breath. a group made up of inspiratory and expiratory neurons in the ventrolateral medulla. It is currently thought that the respiratory cycle of inspiration and expiration is generated by synaptic interactions within these groups of neurons. which supply the diaphragm and other thoracic and abdominal muscles. inspiration is characterized by an augmenting discharge of medullary neurons that terminates 44 . in turn they drive cranial motor neurons. Three main aggregations of neurons are involved: a group consisting mainly of inspiratory neurons in the dorsomedial medulla. Neurally. central organization of respiratory neurons The respiratory rhythm is generated within the pons and medulla. which govern the activity of muscles in the upper airways and the activity of spinal motor neurons. The inspiratory and expiratory medullary neurons are connected to projections from higher brain centres and from chemoreceptors and mechanoreceptors. 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. and a group in the rostral pons consisting mostly of neurons that discharge in both inspiration and expiration.7 The Respiratory System 7 influenced by higher brain centres and even controlled voluntarily to a substantial degree.

but at a much lower level.7 Control and Mechanics of Breathing 7 abruptly. and gradually declines until the onset of expiratory neuron activity. Post-inspiratory neurons are responsible for the declining discharge of the inspiratory muscles that occurs at the beginning of expiration. but pontine neurons and input from stretch receptors in the lung help control the length of inspiration. Mechanically. This type of breathing. is caused by self-excitation of the inspiratory neurons and perhaps by the activity of an as yet undiscovered upstream pattern generator. is called apneustic breathing. this discharge aids in slowing expiratory flow rates and probably assists the efficiency of gas exchange. which produces lung expansion. offswitch. As the activity of the post-inspiratory neurons subsides. expiratory neurons discharge and inspiratory neurons are strongly inhibited. 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. inspiratory activity is restarted. Early inspiratory neurons trigger the augmenting discharge of inspiratory neurons. The full development of this pattern depends on the interaction of several types of respiratory neurons: inspiratory. After a gap of a few milliseconds. early inspiratory. When the vagus nerves are sectioned or pontine centres are destroyed. although in upright humans the lower expiratory intercostal muscles 45 . breathing is characterized by prolonged inspiratory activity that may last for several minutes. post-inspiratory. Then the cycle begins again. and expiratory. This increase in activity. which occasionally occurs in persons with diseases of the brain stem. Offswitch neurons in the medulla terminate inspiration.

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

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

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

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

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

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

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

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

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

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

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

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

with no space between the vocal cords). © www . can be raised voluntarily to 400 litres per minute. The resultant high-speed jet of air is an effective means of clearing the airways of excessive secretions or foreign particles. normally reaching 30 litres per minute in quiet breathing.8 pounds per square inch) by the so-called Valsalva maneuver—a forceful contraction of the chest and abdominal muscles against a closed glottis (i. Airflow velocity.com / Jason Lugo within the lungs can be raised to 130 centimetres of water (about 1. Cough is accomplished by suddenly opening the larynx during a brief Valsalva maneuver..e. The beating of cilia (hairline projections) from cells lining the airways 58 .7 The Respiratory System 7 A cough clears the airways with an abrupt opening of the larynx.istockphoto.

and seven litres. however. In fact.5 litre (approximately one pint) per minute as compared to adult values of 14 breaths. cough resulting only when this action cannot keep pace with the rate at which secretions are produced.7 Control and Mechanics of Breathing 7 normally maintains a steady flow of secretions toward the nose. it is reasonable to question what keeps the lungs’ alveolar walls (also fluidcovered) from sticking together and thus eliminating alveolar airspaces. totaling about 0. Normal lungs. 500 millilitres. respectively. 59 . If the force of surface tension is responsible for the adherence of parietal and visceral pleurae. An infant takes 33 breaths per minute with a tidal volume (the amount of air breathed in and out in one cycle) of 15 millilitres. contain a substance (a phospholipid surfactant) that reduces surface tension and keeps alveolar walls separated. such adherence occasionally does occur and is one of the dreaded complications of premature births.

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

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

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

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

Because of this decreased affinity. a relatively small decline in the partial pressure of oxygen in the blood is associated with a relatively large release of bound oxygen. of the blood). Conversely. a salt in the red blood cells that plays a role in liberating oxygen from hemoglobin in the peripheral circulation).3-DPG. This reserve is available to meet increased oxygen demands.7 The Respiratory System 7 extracted by the cells depends on their rate of energy expenditure. or 2. binding of these substances to hemoglobin affects the affinity of hemoglobin for oxygen. or pH. carbon dioxide.3-DPG decrease the affinity of hemoglobin for oxygen. and the curve is shifted 64 . carbon dioxide. carbon dioxide. including hydrogen ions (which determine the acidity.3-diphosphoglycerate (2.3-DPG result in an increased affinity of hemoglobin for oxygen. with the binding of oxygen. as occurs with anemia or extreme exercise.) Increases in hydrogen ions. Reductions in normal concentrations of hydrogen ions. During extreme exercise the quantity of oxygen remaining in venous blood decreases to 10 to 25 percent. At rest. venous blood returning to the lungs still contains 70 to 75 percent of the oxygen that was present in arterial blood. A rightward shift of the curve is thought to be of benefit in releasing oxygen to the tissues when needs are great in relation to oxygen delivery. and 2. Hemoglobin binds not only to oxygen but to other substances as well. an increased partial pressure of oxygen is required to bind a given amount of oxygen to hemoglobin. and 2. and the oxygen-dissociation curve shifts to the right. changes in the structure of the hemoglobin molecule occur that affect its ability to bind other gases or substances. At the steepest part of the oxygendissociation curve (the portion between 10 and 40 mm of mercury partial pressure). (Affinity denotes the tendency of molecules of different species to bind to one another. Although these substances do not bind to hemoglobin at the oxygen-binding sites.

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

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

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

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

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

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

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

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

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

Two pathways are available: 1. It begins with 74 . and transported by blood flow to the periphery of the cells where it is discharged to reach the mitochondria by diffusion. the aerobic metabolic pathway is therefore preferable. or even the organism. The supply of oxygen to the mitochondria at an adequate rate is a critical function of the respiratory system. In contrast. aerobic metabolism has a higher yield (36 molecules of ATP per molecule of glucose) and results in “clean wastes”—water and carbon dioxide. and since each cell must produce its own ATP (it cannot be imported). Because oxidative phosphorylation occurs only in mitochondria. and 2.7 The Respiratory System 7 the breakdown of foodstuffs. the number of mitochondria in a cell reflects its capacity for aerobic metabolism. which requires oxygen and involves the mitochondria. For any sustained highlevel cell activity. or fermentation. which operates in the absence of oxygen. The transfer of oxygen to the mitochondria involves several structures and different modes of transports. will die. whereas they usually have a reasonable supply of substrates in stock. or its need for oxygen. Oxygen is collected from environmental air. anaerobic glycolysis. 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. which are easily eliminated from the body and are recycled by plants in the process of photosynthesis. or substrates. aerobic metabolism. transferred to blood in the lungs. many cells. because the cells maintain only a limited store of highenergy phosphates and of oxygen. If oxygen supply is interrupted for a few minutes.

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

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

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

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

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

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

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

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

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

approximately in proportion to the reciprocal of the square root of the increasing gas density. provides a greater respiratory advantage for deep diving.640 feet) in the sea and more than 680 metres (2. At the extreme depths now attainable by humans— some 500 metres (1. which in a mixture with less than 4 percent oxygen is noncombustible.5 bar. it may cause the rapid onset of convulsions. In mixed-gas diving. The maximum breathing capacity and the maximum voluntary ventilation of a diver breathing compressed air diminish rapidly with depth. At a partial pressure greater than 1. Thus the practice of using an inert gas such as helium as the oxygen diluent at depths where nitrogen becomes narcotic.5 bar (“surface equivalent value” = 150 percent). Oxygen in excess can be a poison. The term carbon dioxide retainer is commonly applied to a diver who fails to eliminate carbon dioxide in the normal manner. High values of end-tidal carbon dioxide with 84 . inspired oxygen is therefore maintained at a partial pressure somewhere between 0. and after prolonged exposures at somewhat lower partial pressures it may cause pulmonary oxygen toxicity with reduced vital capacity and later pulmonary edema. has the additional advantage of providing a breathing gas of lesser density.2 and 0.230 feet) in the laboratory—direct effects of pressure upon the respiratory centre may be part of the “high-pressure neurological syndrome” and may account for some of the anomalies of breathlessness (dyspnea) and respiratory control that occur with exercise at depth. The use of hydrogen. like an anesthetic. 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.7 The Respiratory System 7 increased. but at great depths the inhomogeneity of alveolar ventilation and the limitations of gas diffusion appear to require oxygen provision at greater than normal levels.

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

86 . Other possible causes of pulmonary barotrauma include retention of gas by a diseased portion of lung and gas trapping due to dynamic airway collapse during forced expiration at low lung volumes. can result in a sometimes life-threatening condition known as decompression sickness.6 feet). 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. even from depths as shallow as 2 metres (6. Inadequacy of diver decompression. Decompression sickness is caused by the formation of bubbles from gases that were dissolved in the tissues while the diver was at an increased environmental pressure.7 The Respiratory System 7 during ascent causes such accidents and is likely to occur if the diver makes a rapid emergency ascent.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In 1906 at the Pasteur Institute. with bulging eyes. and a low-grade fever. Catarrhal symptoms are those of a cold. and pertussis) vaccine. About 100 years later. the French bacteriologists Jules Bordet and Octave Gengou isolated the bacterium that causes the disease. undoubtedly it had existed for a long time before that. later Haemophilus pertussis. and still later Bordetella pertussis. ear infections. Complications of whooping cough include pneumonia. It was first called the Bordet-Gengou bacillus. with a short dry cough that is worse at night. and occasionally convulsions and indications of brain damage. and convalescent—which together last six to eight weeks. In the paroxysmal state. red eyes. variable in duration but commonly lasting four to six weeks. Now included in the DPT (diphtheria. Immunization is routinely begun at two months of age and requires five shots for maximum 106 . slowed or stopped breathing. The first pertussis immunizing agent was introduced in the 1940s and soon led to a drastic decline in the number of cases. During the convalescent stage there is gradual recovery. the illness progresses through three stages—catarrhal. and be dazed and apathetic. the name pertussis (Latin: “intensive cough”) was introduced in England. tetanus. paroxysmal. there is a repetitive series of coughs that are exhausting and often result in vomiting. Beginning its onset after an incubation period of approximately one week. but the periods between coughing paroxysms are comfortable. After one to two weeks the catarrhal stage passes into the distinctive paroxysmal period. The infected person may appear blue. it confers active immunity against whooping cough to children. The disease was first adequately described in 1578.7 The Respiratory System 7 Whooping cough is passed from one person directly to another by inhalation of droplets expelled by coughing or sneezing. Whooping cough is worldwide in distribution and among the most acute infections of children.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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. which is replaced by holes characteristic of emphysema. antibiotics. and each year about 30.000 people in the United States die from COPD. which gives rise to symptoms of bronchitis. The only therapeutic intervention shown to alter the course of COPD is removal of the noxious trigger. which 137 . Other early symptoms of the condition include a “smoker’s cough” and daily sputum production. particularly if severe enough to warrant hospital admission. either bacterial or viral. it is increasingly recognized that COPD has secondary associations. and the burning of certain fuels in poorly ventilated areas. Exacerbations are triggered by infection. Identifying and treating these secondary problems via pulmonary rehabilitation (supervised exercise) and other methods may improve the functional status of the lungs.000 people in the United Kingdom and roughly 119. indicate a poor prognosis. COPD is distinguished pathologically by the destruction of lung tissue.7 Diseases and Disorders of the Respiratory System 7 combination of signs and symptoms of emphysema and bronchitis. Therefore. which causes increased lung volume and manifests as breathlessness. which work against bacteria. Patients with COPD are vulnerable to episodic worsening of their condition (called exacerbation). particularly lung cancer. Coughing up blood is not a feature of COPD and when present raises concern about a second. air pollution. Sources of noxious particles that can cause COPD include tobacco smoke. It is a common disease. Although primarily a lung disease. including muscle weakness and osteoporosis. Frequent exacerbations. tobacco-related condition. These pathological characteristics are realized physiologically as difficulty in exhaling (called flow limitation). are not always required. and by a tendency for excessive mucus production in the airway.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7 Allergic and Occupational Lung Diseases and Acute Respiratory Conditions 7 Carbon Monoxide Poisoning Carbon monoxide poisoning is a common and dangerous hazard. carbon monoxide concentrations of less than 1 percent in inspired air seriously impair oxygen-hemoglobin binding capacity. and in a mixture of these gases hemoglobin will preferentially bind to carbon monoxide. Carbon monoxide is produced by incomplete combustion. a condition in which hemoglobin is deficient. Judgment is also impaired. The carbon monoxide inhaled by smokers who smoke more than two packs of cigarettes a day may cause up to 10 percent hemoglobin saturation with carbon monoxide. 183 . Hemoglobin’s affinity for carbon monoxide is 200 times greater than for oxygen. The immediate treatment for acute carbon monoxide poisoning is assisted ventilation with 100 percent oxygen. For this reason. leaving only 60 percent available to bind to oxygen). British physiologist John Scott Haldane pioneered the study of the effects of carbon monoxide at the end of the 19th century. The partial pressure of oxygen in the tissues in carbon monoxide poisoning is much lower than when the oxygen-carrying capacity of the blood has been reduced an equivalent amount by anemia. the subject feels dizzy and is unable to perform simple tasks. including combustion of gas in automobile engines. as part of his detailed analysis of atmospheres in underground mines. and for a long period it was a major constituent of domestic gas made from coal (its concentration in natural gas is much lower). When the carbon monoxide concentration in the blood reaches 40 percent (when the hemoglobin is 40 percent saturated with carbon monoxide. A 4 percent increase in the blood carbon monoxide level in patients with coronary artery disease is believed to shorten the duration of exercise that may be taken before chest pain is felt.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and (2) those measuring respiratory function. David McNew/Getty Images Pulmonary Function Test A pulmonary function test is a procedure used to measure various aspects of the working capacity and efficiency of the lungs and to aid in the diagnosis of pulmonary disease. Tests of ventilatory function include the following measurements: residual 202 .7 The Respiratory System 7 A spirometry test measures lung capacity and degree of airflow obstruction. There are two general categories of pulmonary function tests: (1) those that measure ventilatory function. or the transfer of gas between the alveoli and the blood. or lung volumes and the process of moving gas in and out of the lungs from ambient air to the alveoli (air sacs).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

the increased oxygen speeds clearance of carbon monoxide from the blood and reduces damage done to cells and tissues. from the increased availability of oxygen to the body (because of an increase in the partial pressure of oxygen). The therapeutic benefits of a high-pressure environment derive from its direct compressive effects. which increases oxygen availability to the body in therapeutic treatment. In the treatment of carbon monoxide poisoning. a major effect of the elevated pressure is shrinkage in the size of the gas bubbles that have formed in the tissues.5 to 3 times higher than ordinary atmospheric pressure. Chris McGrath/ Getty Images used for medical treatment are usually 1.7 The Respiratory System 7 A hyperbaric chamber creates a high-pressure environment. 222 . In the treatment of decompression sickness. or from a combination of the two. for example.

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

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

For example. 225 . 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. In addition.7 Approaches to Respiratory Evaluation and Treatment 7 Another important factor behind the advance of respiratory medicine has been the elucidation of cellular processes that underlie respiratory disease. 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. such as the arterial blood gas test to determine blood oxygen levels in persons suffering from chronic respiratory disease. As researchers and physicians continue to uncover new information about the human respiratory system. 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.

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

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

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

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

30. structure of. 210. 197 bronchopulmonary dysplasia. 221 asbestosis. 30. 103. 171–173 asphyxiation. 96. 164. 52. 33–34 stem. 174 Buerger disease. 189–192. 103 anemia. 188–189 alveoli. 79–80. 194 asthma. 39 alcoholism. 97. 129. 127. 94. 52. 100–102.130–131. 188 bird fancier’s lung. 197. 172. 187 byssinosis. 173. 175. 213 atelectasis. 169. 147. 169. 184 Actinomyces. 131. 223 bronchitis. 212–214 aortic body. 75 acidosis. 184–186 altitude sickness. Georgius. Jules. 176. 38. structure and function of. 136. 208. 51. 131–133. 153. 124–125. 168. 218–220 asbestos. 171 antibiotics.INDEX A acid–base balance. 187 anesthesia. 141–144 B barotrauma. 152–156. 196. 86. 205–208 brown lung. 186. 211. 184. 114. Paul. 77 Agricola. 115. 35. 85 artificial respiration. 166 black lung. 64. 171 AIDS. 28–29 bronchiectasis. 230 . 117. 211. 109. 73. 110. 209 animals. 126 arterial gas embolism. 175. 50 Breuer. 81. Josef. 30. 135. 182. 217 bronchoscopy. 193 anthracosis. 75. 169 lung. 112–113. 127. 46. 159. 168–169. 27 adenosine triphosphate (ATP). 92. 123. 214 antihistamines. 76. 91. 217 Bert. 111 Adam’s apple. 160–164. 137. 134. 152. 99–100. 33–34 bronchiolitis. 159. 152. 93. 107. 169. 48 apnea. structure of. 111. 111. 171–173. 198. 171. 170–171 Bordet. 49 bronchi. 198 bronchioles. 174–175 C cancer. 118–119 air–blood barrier. 74. 106 bradykinin. 81. 46. 113 alkalosis. 137. 181. 42. 122. structure and function of. 102. 108. 116. 34–35 amantadine.

52 chloride shift. 204. 197. 218 dyspnea. 158. 34 cold. 130. 97. 62. 93. 52 Cheyne-Stokes breathing. 48. 187. 78. 171. 129. 65. 86. 84. 191–193 drowning. 197. 156–158. 213 hemoglobin. 80. 30. 190. 81–86. 192. 193–195. 63. 138. 186. 149. 87. 216–217 Hering. 190 histamine. 198 croup. 47. 98. 156. 60. 133–136. 220. 122. 50. 106. 85. Ewald. 158 diffusion limitation. 211. 95. 115. 166 fungi. 25. 47. 209. 160 HIV. 170. common. 49 high altitudes. 144. 197–198 H Haldane. 131. 94. 56. 44. 184. 95. 117. 222 decongestants. 223 eosinophilic granuloma. 168. 182 G gas exchange. 122. 196–197. 198. 210.7 Index 181. 98–99 epiglottitis. 21. 51–52. 88–91. 102. 69–72 Gengou. 108. 81. 72 diphtheria. 214 diving. 175. 183 hay fever. 81 central nervous system disease. 207 physiology of. 127–129. 136–138. 98–99 cystic fibrosis. 215 carotid body. 66. 46. 164. 112. 98. 217 Clara cells. 98–99 epinephrine. 75. 212 exercise (training). 137. 164 coughing blood. 188–189. 147. 130. 161. 78. 25. 183. 221 cardiopulmonary resuscitation (CPR). 135. abnormal. 130. 183. 145. 106 glycolysis. 199. 88 corticosteroids. 75–78. 92. 177. 215. 145–148. 87. 58–59. 174. 106. 159. 151 D decompression sickness. Octave. 64. 79–81. 213 cause of. 201 F farmer’s lung. 27. 74 goblet cells. 49 Hering-Breuer reflex. 196. 80. 50. 211–212 diaphragm. 65. John Scott. 96. 94. 159. 201. 150 epiglottis. 91. 132. 132 types of. 136. 64. 215. 119 231 . 221. 50. 189–192. 84. 143. 122. 105–106. 182. 67. 137. 157–158. 69. 137. 190. 180. 67 chronic obstructive pulmonary disease (COPD). 111. 187. 223 7 E emphysema. 30 Goodpasture syndrome. 98. 47.

41. 50. 149. 173 cancer of. 87. 139. 145 K kidney. 99. 44. 147. 198. 110. 117 mesothelioma. 196 laryngitis. 127 hygiene. 151. 98. 163 hydrothorax. 221 metabolism. 68. 26 232 . 190. 199. 114. 125 hypoventilation. 81 mountain sickness. 93. 78 anaerobic. 209. 31 transplantation of. 138–141. 99 mediastinoscopy. 159 congestion of. 76 Monge disease. 221 collapse of. 173. 110. 223 lung ventilation/perfusion scan. 51–52. 144–145. 173. 172. 177 size of. 83. 45. 152–156. 169. 149 influenza. 141. 100 lungs N nephritis. 127. 208 medulla. 83 hypersensitivity pneumonitis. 204–205 M measles. 126 hypoxemia. 221–222 hypercapnia. 150. 103. 94 nerves laryngeal. 55–56. 149. 74. 103 H1N1. 156–158. 73–78. 167. 182. 31. 127. 38. 199 bird flu. 74. 178. 81 mucoviscidosis. 113–114. 197 development of. 138. 184 L Laënnec. 181. 37. 119 hyperbaric chamber. 38–40 infarction. 184–186 hypothyroidism. 214 leukemia. 69. 49. 178. 166–167 hyperventilation. 215. 95–96 larynx. 96. 135–136. 81 aerobic. 91. 128. 52. 176. 186–188 I idiopathic pulmonary fibrosis. 46–48.7 The Respiratory System 7 hookworm. 114–115. 92. 143. 215. structure and function of. 129. 87. 204. 217 hypoxia. 70. René-ThéophileHyacinthe. 104 vaccine. 102–105. 117. 171–173. 26–28 Legionnaire disease. 26. 208–209 mediastinum. 81–82. 50 meningitis. 76–77. 138. 198. 47. 94. 88. 122.

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

99. 220–221 thoracic emphyema. 94 staphylococci. 53. 96–98 trench mouth. 93. 173 Valsalva maneuver. 96. 92. 95 tuberculosis. 23–24. 138. 164. 127–129 thoracic squeeze. 143. 78. 152. 97 V vaccination. 182. 28–30 tracheitis. 178. 56. 97. 92 streptococcal bacteria. 220 typhoid. 137. 91. 103. 97. 116. 97 trachea. 198. 109. 111. 209 swimming. 133–135. 25. 136. 204. 104 tetanus. 94–95 tonsils. 197. 87. 164 snoring. 69 vestibular folds. 27–28 T Tamiflu. 119. 95. 106. 108. 106 thoracentesis. 92. 176. 192–193 tonsillitis. 94 smoking. 92.102. 175. 172. 92. 131–132. 164. 170. 53. 163. 96. 91 vocal chords. 94–95. 27–28 vitamin C. 183. 110. 129. 107. 128. 105–107 Z zanamivir. 114–121.7 The Respiratory System 7 smallpox. 93. 102. 81–86 syphilis. 218 sneezing. 125. structure and function of. 122. 99. 208. 130. 123–124 sore throat. 88. 33. 150. 130. 123. 58 ventilation–blood flow imbalance. 95. 97 smell. 171. 124 W whooping cough. 97. 91. 122. 138. 103. 104–105 234 . 97. 87. 91. 118. 199. 87. 146 strep throat. 103. 214 surgery. 199. false. 153. 92. 94. 155–156. 171. 138. 21. 95.

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