Kosin Medical Journal 2016;31:11-18.

http://dx.doi.org/10.7180/kmj.2016.31.1.11 KMJ
Review Article

Aging of the respiratory system

Seung Hun Lee, Su Jin Yim, Ho Cheol Kim

Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do,
Korea

Changes in the respiratory system caused by aging generally include structural changes in the thoracic cage
and lung parenchyma, abnormal findings on lung function tests, ventilation and gas exchange abnormalities,
decreased exercise capacity, and reduced respiratory muscle strength. Decreased respiratory system
compliance caused by reduced elastic recoil of the lung parenchymaand thoracic cage is related to decreased
energy expenditure by the respiratory system. Lung function, as measured by 1-second forced expiratory
volume and forced vital capacity (FVC), decreases with age, whereas total lung capacity remains unchanged.
FVC decreases because of increased residual volume and diffusion capacity also decreases. Increased
physiological dead space and ventilation/perfusion imbalance may reduce blood oxygen levels and increase
the alveolar-arterial oxygen difference. More than 20% decrease in diaphragmstrength is thought to
beassociated withaging-related muscle atrophy. Ventilation per minute remains unchanged, and blood carbon
dioxide concentration does not increase with aging. However, responses to hypoxia and hypercapnia are
decreased. Exercise capacity also decreases, and maximum oxygen consumption decreases by >1%/year.
Consequence of these changes, many respiratory diseases occur with aging. Thus, it is important to recognize
these aging-related respiratory system changes.

Key Words: Aging, Respiratory system

The worldwide aging population is rapidly in-
creasing and Korea also expects to become an
ultra-aging society as elderly individuals aged
65 years or older will comprise more than 25
% of its total population by 2025.1
Changes in the respiratory system with aging
do not cause serious problems such as airway
obstruction or parenchymal lung disease in
healthy people because they have reserve lung
capacity. However, when the affected person

The human body undergoes a variety of ag- has comorbid underlying lung disease due to pre-
ing-related changes including changes in the res- vious infections or smoking, the reserve is re-
piratory system. However, normal variations of duced, and therefore, lung problems can arise

such changes may not be easily distinguishable more easily. The changes in the respiratory sys-
from pathological changes because of marked tem caused by aging generally include structural
interindividual differences.2 changes in the thoracic cage and lung paren-

Corresponding Author: Ho Cheol Kim, Research Building No.205, Gyeongsang National University Received: Jan. 08, 2016
School of Medicine, 79, Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Korea Revised: Jan. 08, 2016
Tel: +82-55-750-8684 Fax : +82-55-750-8618 E-mail: hochkim@gnu.ac.kr Accepted: Jan. 11, 2016

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Kosin Medical Journal 2016;31:11-18.
chyma, abnormal findings on pulmonary func-
tion tests, ventilation and gas exchange abnor-
mality, reduced respiratory muscle strength, and
decreased exercise capacity. In this review, the
authors intend to present the physiological alter-
ations caused by aging such as changes in respi-
ratory system dynamics, gas exchange abnor-
malities, and changes in exercise capacity and
respiratory muscle strength.
Changes in respiratory system structures
and dynamics
Structural changes induce an increase in the
anterior and posterior diameters of thoracic
cage, causing it to assume a round shape.
Increased stiffness and reduced compliance of
the thoracic wall is induced by aging-related cal-
cification of the joint cartilage of the thorax and
spinal scoliosis caused by osteoporotic changes.
A study that measured the compliance of the
thoracic wall in 61 healthy adults ranging from
24 to 75 years old, reported that the thoracic
compliance was reduced according to the partic-
ipants’ age.1 Reduced compliance of the thorax
causes a reduction of energy efficiency increas-
ing the effort required for breathing.2 Additional
aging-related changes include periphery airway
calcification, reduction of elasticity due to
12
changes in elastic fibers of small airways
(reduction by about 0.1~0.2 cm H2O each year),
reduction in the proportion of lung parenchyma
versus the lung volume, and mucous gland hyper-
trophy in addition to structural changes in lung
parenchyma.3,4
Change in Lung Function
Aging-induced changes in the respiratory sys-
tem, such as reduction of compliance and of
respiratory muscle strength, result in changes
in the results of pulmonary function tests.5-11
Lung function reaches its peak when in-
dividuals are in their early 20s, is maintained
for some time, and then decreases normally with
aging. In general, it is known that 1-second
forced expiratory volume (FEV1) reduces by
about 20 mL/year up to the age of 25~39 years,
whereas it reduces by 35 mL/year in those over
65 years of age.12,13 The reduction rates of forced
vital capacity (FVC) and FEV1 increase with in-
creasing age, but they do not display a linear
reduction and the reduction rates are faster in
men than in women.
Total lung capacity (TLC) does not change or
slightly reduces during aging, but residual volume
(RV) is increased and vital capacity (VC) is
reduced. Compared to a 20-year-old person, the

residual volume increases by about 50% and vital
capacity reduces by 75% in a 70-year-old person.
Therefore, the ratio of RV/TLC increases with
age, and this increase is considered to be due
to reduced lung elasticity and thoracic wall com-
pliance, weakened expiratory muscle strength,
and increased closing lung volume.6,14
The peak expiratory flow rate (PEFR) reaches
its peak at the age of approximately 30~35 years
and subsequently declines, particularly after the
age of 45. After the age of 50, PEFR reduces
at the rate of 4 L/min/year in men and 2.5
L/min/year in women. These reductions indicate
small airway disease based on the flow rate-vol-
ume curve.14
Small changes in airway resistance occur dur-
ing aging, which can be explained by a reduction
in the diameter of the peripheral airway; how-
ever, the diameter of the central airway is in-
creased with aging and this offsets the effects
of increased peripheral airway resistance,15
which comprises only 10% of the total airway
resistance.
The diffusion capacity for carbon monoxide
(DLCO) also decreases with age by 0.2
mLCO/min/mmHg/year in men and by 0.15
mLCO/min/mmHg/year in women. The degree
of decreases in women is reported to be lesser
than that in men, possibly due to the influence
of estrogen, which maintains integrity of the
Aging of the respiratory system
blood vessel. A study by Stam et al. reported
a decrease in the diffusing capacity of 55 healthy
persons compared with aged ≥70 years, even
after adjusting for the dimension of the alveoli.
This decrease in diffusing capacity may likely
be caused by aging-induced changes in the al-
veolar- capillary membrane.16
With aging-induced ventilation/perfusion im-
balance, physiological dead space increases. At
the age ranged 15 to 20 years old, the dead space
is about 13% of alveolar ventilation, but it in-
creases to 32% at the age ranged from 61 to
75 years.17 In study of Miller et al., it was reported
that the physiological dead space in old healthy
person was about 235 ± 67.5 ml and it showed
it was increased by more than 50% compared
to young healthy person whose physiological
dead space was 150 ml.18 With the increase of
dead space, the normal arterial oxygen’s partial
pressure in the elderly people is lowered than
in younger people while the differences in the
concentrations of alveolar arterial oxygen, that
is, (Aa) DO2, is increased. However, the minute
ventilation is not decreased and there is no occur-
rence of the carbon dioxide exchange impair-
ment by aging, therefore, the occurrence of res-
piratory acidosis should be considered as patho-
logical in old ages as well.
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Kosin Medical Journal 2016;31:11-18.
Changes in the respiratory muscle strength
Decreased muscle strength is a general con-
sequence of aging, and affects the respiratory
muscles as well.19,20 Respiratory muscle strength
can be determined by measuring various param-
eters such as the maximum trans-diaphragmatic
pressure (Pdi max), maximal voluntary ven-
tilation (MVV), and maximal inspiratory pressure
(MIP). All these parameters have been found to
be decreased in elderly people.21,22
In a study that measured the muscle strength
of the diaphragm, it was found that elderly people
(65 to 75 years old) show a decrease of approx-
imately 25% in the Pdi max compared to young
adults (19 to 28 years old).19 A study by Polkey
et al. also showed similar results,23 and the MIP
was 30% higher in men than in women irre-
spective of age. The change in H2O/year in men
ranging from 65 to 85 years old was found to
be 0.8-2.7 cm.
The reduced strength of the diaphragm with
aging is associated with muscle atrophy and with
decrease of fast fibers that create a higher level
of tension. Reduction of diaphragmatic muscle
strength increases the respiratory rate in the eld-
erly, which results in fatigue to the diaphragm,
and may eventually cause ventilatory failure.
Thus, the reduction of respiratory muscle
strength due to aging may not be a serious prob-
14
lem in healthy individuals, but if the ventilation
demands are increased due to pulmonary dis-
ease, it can be a major problem resulting in respi-
ratory failure
The cross-sectional area of the intercostal
muscles is slightly reduced, while that of the ex-
piratory muscles is reduced to a much greater
extent, at the age of 50 years or higher.24 In
contrast, no change in the thickness the dia-
phragm occurs during aging. However, the re-
duction of compliance in the chest wall results
in a reduction in the curvature causing a reduc-
tion in Pdi max.
Reduction in respiratory muscle strength in
the elderly has shown to be associated with nutri-
tional status, and BMI has been reported to have
a significant correlation with the MIP as well
as with the maximal expiratory pressure.25
Responses to hypoxia and hypercapnia
Minute ventilation remains the same between
the younger and the older age groups. Although
the tidal volume is reduced with age, the minute
ventilation is maintained by increasing the respi-
ration rate. However, the ventilator response to
hypoxemia or to increased carbon dioxide con-
centration may be inadequate in the elderly.26
A study conducted by Kronenberg and Drage

in 8 healthy young and 8 healthy elderly partic-
ipants, revealed that the response to hypoxia
was reduced by 50% and the response to hyper-
capnia was also reduced by 40% in the elderly
individuals. Although the mechanism is unclear,
these changes might have been caused by dys-
function of chemosensory receptors and by
structural changes in the lung and thoracic
cage.27 Poulin et al. reported that the ventilation
demands for the generation of carbon dioxide
were increased during aging in 224 healthy per-
sons aged between 56 and 85 years old. This
change was considered to be caused by aging-in-
duced increases in the end expiratory-arterial
carbon dioxide concentration and the ven-
tilation/ perfusion imbalance.28
Changes in exercise capacity
The maximal oxygen consumption (VO2max)
which is an indicator of exercise capacity, reach-
es its peak level when individuals are between
the ages of 20 and 30 years and then decreases
by approximately 1% every year depending on
the individual capacity of physical activity.
Generally, VO2max decreases at a rate of 32
mL/min/ year in men and at a rate of 14 mL/min/
year in women after the age of 20-30 years. In
a longitudinal study on the effects of aging on
Aging of the respiratory system
lung function at rest and during exercise in
healthy older people, McClaran et al. confirmed
that VO2max decreased by 11% over 6 years.15
Changes in cough reflex
The cough reflex weakens with aging. This
change may be attributed to the decrease in
cough sensation, increased activation threshold
of the vagus and occipital nerves, decreased ten-
sion of smooth muscles, and reduction of cogni-
tive capacity.29,30 Respiratory muscle strength al-
so decreases so that coughing cannot adequately
remove a foreign material or secretion. Such
weakening of the cough reflex contributes to
the increase in the incidence of aspiratory pneu-
monia in elderly individuals.30
Conclusion
The various changes that occur in the respira-
tory system of elderly individuals result in an
increased risk for a variety of respiratory
diseases. In order to understand respiratory dis-
eases that occur in elderly individuals, it is im-
portant to recognize aging-related changes in
the respiratory system. Based on a thorough un-
derstanding of these changes, it might be possible
15
Kosin Medical Journal 2016;31:11-18.

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9. Sprung J, Gajic O, Warner DO. Review article:

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Kosin Medical Journal 2016;31:11-18.

Peer Reviewer’s Commentary

Lung function, as measured by 1-second forced expiratory volume and forced vital capacity (FVC),
decreases with age, whereas total lung capacity remains unchanged. FVC decreases because of
increased residual volume and diffusion capacity also decreases. Increased physiological dead space
and ventilation/perfusion imbalance may reduce blood oxygen levels and increase the alveolar-arterial
oxygen difference. If we make understand the changes in respiratory function that occur with increasing
age, there is meaningful results in maintaining a healthy life.
(Editorial Board)

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