Respiratory system

● The main function of the respiratory system is to provide oxygen to body cells for energy
metabolism and to eliminate carbon dioxide, a byproduct of metabolism.
● Because these gases must be carried to and from the cells in the blood, the respiratory
system works closely with the cardiovascular system to accomplish gas exchange.
This activity has two phases:
■ External gas exchange occurs between the outside atmosphere and the blood.
■ Internal gas exchange occurs between the blood and the tissues.

● External exchange takes place in the lungs, located in the thoracic cavity. The remainder of
the respiratory tract consists of a series of passageways that conduct air to and from the
lungs. No gas exchange occurs in these regions.
UPPER RESPIRATORY PASSAGEWAYS
● The upper respiratory passageways consist of the nose and pharynx (throat). Air can also be
exchanged through the mouth, but there are fewer mechanisms for cleansing the air taken in
by this route.

NOSE
● Air enters through the nose, where it is warmed, filtered, and moistened as it passes
over the hair-covered mucous membranes of the nasal cavity. Cilia—microscopic
hair-like projections from the cells that line the nasal passageways— sweep dirt and
foreign material toward the throat for elimination. Material that is eliminated from the
respiratory tract by coughing or clearing the throat is called sputum. Receptors for the
sense of smell are located within bony side projections of the nasal cavity called
turbinate bones or conchae.
● In the bones of the skull and face near the nose are airfilled cavities lined with a
mucous membrane that drain into the nasal cavity. These chambers lighten the bones
and provide resonance for speech production. These cavities, called sinuses, are
named specifically for the bones in which they are located, such as the frontal,
sphenoidal, ethmoidal, and maxillary sinuses. Together, because they are near the
nose, these cavities are referred to as the paranasal sinuses.
PHARYNX
● Inhaled air passes into the throat, or pharynx, where it mixes with air that enters
through the mouth and also with food destined for the digestive tract. The pharynx is
divided into three regions,
■ The nasopharynx is the superior portion located behind the nasal cavity.
■ The oropharynx is the middle portion located behind the mouth.
■ The laryngopharynx is the inferior portion located behind the larynx.
The tonsils, lymphoid tissue described in Chapter 10, are in the region of the pharynx
■ The palatine tonsils are on either side of the soft palate in the oropharynx.
■ The single pharyngeal tonsil, commonly known as the adenoids, is in the nasopharynx.
■ The lingual tonsils are small mounds of lymphoid tissue at the posterior of the tongue.

LOWER RESPIRATORY PASSAGEWAYS AND LUNGS

● Air moves from the pharynx into the larynx, commonly called the voice box, because it
contains the vocal folds, or cords. The larynx is at the top of the trachea, commonly called
the windpipe, which conducts air into the bronchial system toward the lungs.

THE LARYNX
● The larynx is shaped by nine cartilages, the most prominent of which is the anterior thyroid
cartilage that forms the “Adam’s apple”. The small leaf-shaped cartilage at the top of the
larynx is the epiglottis. When one swallows, the epiglottis covers the opening of the larynx
and helps prevent food from entering the respiratory tract. The larynx contains the vocal
folds, bands of tissue that are important in speech production. Vibrations produced by air
passing over the vocal folds form the basis for voice production, although portions of the
throat and mouth are needed for proper speech articulation. The opening between the vocal
folds is the glottis (the epiglottis is above the glottis).
THE TRACHEA
● The trachea is a tube reinforced with C-shaped rings of cartilage to prevent its
collapse (you can feel these rings if you press your fingers gently against the front of
your throat). Cilia in the trachea’s lining move impurities up toward the throat, where
they can be eliminated by swallowing or by expectoration, coughing them up.
● The trachea is contained in a region known as the mediastinum, which consists of the
space between the lungs together with the organs contained in this space. In addition
to the trachea, the mediastinum contains the heart, esophagus, large vessels, and
other tissues.

THE BRONCHIAL SYSTEM

● At its lower end, the trachea divides into a right and a left primary bronchus, which
enter the lungs. The right bronchus is shorter and wider; it divides into three
secondary bronchi in the right lung. The left bronchus divides into two branches that
supply the left lung. Further divisions produce an increasing number of smaller tubes
that supply air to smaller subdivisions of lung tissue. As the air passageways progress
through the lungs, the cartilage in the walls gradually disappears and is replaced by
smooth (involuntary) muscle.
● The smallest of the conducting tubes, the bronchioles, carry air into the microscopic
air sacs, the alveoli, through which gases are exchanged between the lungs and the
blood. It is through the ultrathin walls of the alveoli and their surrounding capillaries
that oxygen (O2) diffuses into the blood and carbon dioxide diffuses out of the blood
for elimination.
THE LUNGS
● The cone-shaped lungs occupy the major portion of the thoracic cavity. The right lung
is larger and divided into three lobes. The left lung, which is smaller to accommodate
the heart, is divided into two lobes. The lobes are further subdivided to correspond to
divisions of the bronchial network.

A double membrane, the pleura, covers the lungs and lines the thoracic cavity. There are
two pleural layers:
■ The parietal pleura, the outer layer, is attached to the wall of the thoracic cavity.
■ The visceral pleura, the inner layer, is attached to the surface of the lungs.

● The very narrow, fluid-filled space between the two layers is the pleural space. The
moist pleural membranes slide easily over each other within the chest cavity, allowing
the lungs to expand during breathing.

BREATHING
● Air is moved into and out of the lungs by the process of breathing, technically called
pulmonary ventilation. This consists of a steady cycle of inspiration (inhalation) and
expiration (exhalation), separated by a period of rest. Breathing is normally regulated
unconsciously by centers in the brainstem. These centers adjust the rate and rhythm
of breathing according to changes in the blood composition, especially the
concentration of carbon dioxide.
 INSPIRATION
● The breathing cycle begins when
the phrenic nerve stimulates the
diaphragm to contract and flatten,
enlarging the chest cavity. At the same
time, external intercostal muscles
between the ribs elevate and expand the
rib cage. A resulting decrease in
pressure within the thorax causes air to
flow into the lungs. Muscles of the neck
and thorax are used in addition for
forceful inhalation.
● The measure of how easily the
lungs expand under pressure is
compliance. Fluid produced in the
lungs, known as surfactant, aids in
compliance by reducing surface tension
within the alveoli.

EXPIRATION
● Expiration occurs as the breathing muscles relax and the elastic lungs spring back to
their original size. Increased pressure in the smaller thorax forces air out of the lungs.
In forceful exhalation, the internal intercostal muscles contract to lower the rib cage,
and the abdominal muscles contract, pressing internal organs upward against the
diaphragm.

Gas Transport
● Oxygen is carried in the blood bound to hemoglobin in red blood cells. The oxygen is
released to the cells as needed. Carbon dioxide is carried in several ways but is
mostly converted to carbonic acid. The amount of carbon dioxide that is exhaled is
important in regulating the blood’s acidity or alkalinity, based on the amount of
carbonic acid that is formed. Dangerous shifts in blood pH can result from exhalation
of too much or too little carbon dioxide.
WORD PARTS PERTAINING TO THE RESPIRATORY SYSTEM

Suffix Meaning Example

-pnea breathing dyspnea – shortness of breath; painful or

difficult breathing

-oxia level of oxygen hypoxia – decreased amount of oxygen in the

tissues

-capnia level of carbon dioxide hypocapnia – decreased carbon dioxide in the

tissues

-phonia voice aphonia – loss of voice

ROOTS FOR THE RESPIRATORY PASSAGEWAYS

Roots Meaning Example

nas/o nose intranasal – within the nose

rhin/o nose rhinoplasty – repair of the nose

pharyng/o pharynx pharyngeal – pertaining to the pharynx

laryng/o larynx laryngospasm – spasm (sudden contraction) of the larynx

trache/o trachea tracheotome – instrument used to incise the trachea

bronch/o, bronch/i bronchus bronchogenic – originating in a bronchus

bronchiol bronchiole bronchiolectasis – dilatation of the bronchioles

ROOTS FOR THE LUNGS AND BREATHING
Root Meaning Example

phren/o diaphragm phrenic – pertaining to the diaphragm

phrenic/o phrenic nerve phrenicectomy – partial excision of the phrenic

nerve

pleur/o pleura pleurodesis – fusion of the pleura

pulm/o, pulmon/o lung extrapulmonary – outside the lungs

pneumon/o lung pneumonitis – inflammation of the lung;

pneumonia

pneum/o, pneumat/o air, gas; also pneumothorax – presence of air in the thorax
respiration, lung (pleural space)

spir/o breathing spirometer – instrument for measuring

breathing volumes
CLINICAL ASPECTS OF THE RESPIRATORY SYSTEM
● Any disorder that causes resistance to airflow through the respiratory tract or that
limits chest expansion will affect pulmonary function. These disorders may involve the
respiratory system directly, such as infection, injury, allergy, aspiration (inhalation) of
foreign bodies, or cancer; they may also originate in other systems, such as in the
skeletal, muscular, cardiovascular, or nervous systems.
● As noted above, changes in ventilation can affect the blood’s pH (acidity or alkalinity).
If too much carbon dioxide is exhaled by hyperventilation, the blood tends to become
too alkaline, a condition termed alkalosis. If too little carbon dioxide is exhaled as a
result of hypoventilation, the blood tends to become too acidic, a condition termed
acidosis.

INFECTIONS
● A variety of organisms infect the respiratory system. For your reference, some of these
organisms are listed along with the diseases they cause in BOX 12-2. Childhood
immunizations have dramatically reduced the incidence of some infectious respiratory
diseases, such as diphtheria and pertussis (the “D” and “P” in the DTaP vaccine; the
“T” is for tetanus).
PNEUMONIA
● Pneumonia is caused by many different microorganisms, usually bacteria or viruses.
Bacterial agents are most commonly Streptococcus pneumoniae and Klebsiella
pneumoniae. Viral pneumonia is more diffuse and is commonly caused by influenza
virus and adenovirus.
There are two forms of pneumonia
■ Lobar pneumonia, an acute disease, involves one or more lobes of the lung.
■ Bronchopneumonia (bronchial pneumonia) occurs throughout the lung. It begins in
terminal bronchioles that become clogged with exudate and form consolidated (solidified)
patches.
● Pneumonia can usually be treated successfully in otherwise healthy people, but in
debilitated patients, it is a leading cause of death. Immunocompromised patients,
such as those with AIDS, are often subject to a form of fungal pneumonia called
Pneumocystis pneumonia (PCP).
● The term pneumonia is also applied to noninfectious lung inflammation, such as that
caused by asthma, allergy, or inhalation of irritants. In these cases, however, the more
general term pneumonitis is often used.
Respiratory Syncytial Virus
● Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract
infections in infants and young children worldwide. The name comes from the fact that
the virus induces fusion of cultured cells (formation of a syncytium) when grown in the
laboratory. Infection may result in bronchiolitis or pneumonia, but the virus may affect
the upper respiratory tract as well. Most susceptible are premature infants, those with
congenital heart disease, and those who are immunodeficient. Exposure to cigarette
smoke is a definite risk factor.
● The virus usually enters through the eyes and nose following contact with
contaminated air, nasal secretions, or objects. The incubation period is 3 to 5 days,
and an infected person sheds virus particles during the incubation period and up to 2
weeks thereafter. Infection usually resolves in 5 to 7 days, although some cases
require hospitalization and antiviral drug treatments.

Tuberculosis
● The incidence of tuberculosis (TB) has increased in recent years, along with the
increase of AIDS and the appearance of antibiotic resistance in the causative
organism, Mycobacterium tuberculosis (MTB). (This organism, because of its staining
properties, is also referred to as AFB, meaning acidfast bacillus.) The name
tuberculosis comes from the small lesions, or tubercles, that characterize the infection.
The tubercles can liquefy in the center and then rupture to release bacteria into the
bloodstream. Generalized TB is known as miliary tuberculosis because of the many
tubercles that are the size of millet seeds in infected tissue.

● TB symptoms include fever, weight loss, weakness, cough, and hemoptysis, the
coughing up of blood-containing sputum. Accumulation of exudate in the alveoli may
result in consolidation of lung tissue. Active TB is diagnosed by chest x-ray and
laboratory culture of sputum samples to isolate, stain, and identify any causative
organisms. If found, the organisms can be tested for drug susceptibility. These
laboratory studies can take up to 8 weeks, as the TB organism is very slow growing,
so clinicians also use several quick tests to identify tuberculosis infections.

These include:
■ The tuberculin test, a skin test, also known as a Mantoux (man-TOO) test. The test
material, tuberculin, is made from byproducts of the tuberculosis organism. PPD (purified
protein derivative) is the form of tuberculin commonly used. In 48 to 72 hours after
tuberculin is injected below the skin, a hard, raised lump appears if a person has been
infected with the TB organism. This test does not distinguish active from inactive cases.

■ IGRA, a rapid blood test to diagnose TB. This is an immunologic test with the full name
interferon-gamma release assay. It is used to confirm results of a negative skin test in
people at high risk of having TB.

■ NAA, a sputum test that can confirm a positive TB diagnosis within 24 hours. The full
name is nucleic acid amplification test.

● BCG vaccine is used worldwide to help to prevent TB; it is not used routinely in the
United States because the incidence of TB in this country is relatively low and also
because it invalidates the tuberculin test. The bacillus (B) used for the vaccine is
named for Calmette (C) and Guérin (G), discoverers of this avirulent mycobacterium
strain.

Influenza
● Influenza (“flu”) is a viral respiratory disease associated with chills, fever, headaches,
muscular aches, and cold-like symptoms. It usually resolves in several days, but
severe forms of influenza have caused fatal pandemics, most recently in 1918, 1957,
and 1968. The virus can mutate readily and spread among animals, such as birds or
pigs, and humans.
● Because influenza viruses change so rapidly, scientists must prepare vaccines against
the strains most likely to cause an epidemic in any given year. The virus strains are
grouped into categories A to C, with A the most severe and C the least. They are
further designated H and N with numbers, such as H3N2 and H5N1. The “H” and “N”
represent surface proteins that the virus uses to infect a host.
● Medical personnel combat influenza with vaccines, isolation of infected populations,
destruction of infected animals, and antiviral medications.

Croup
● Croup usually affects children under 3 years of age and is associated with a number of
different infections that result in upper respiratory inflammation. Airway constriction
produces a loud, barking cough, wheezing, difficulty in breathing, and hoarseness. If
croup is severe, the child may produce a harsh, squeaking noise (stridor) when
breathing in through a narrowed trachea. Viral infections, such as those involving
parainfluenza, adenovirus, RSV, influenza, or measles, are usually the cause. Although
 croup may be frightening to parents and children, recovery is complete in most cases
within a week. However, medical treatment is warranted if the child’s respiratory rate is
very high and if the ribs become visible with each inhalation. Home treatments include
humidifying room air or having the child breathe in steam. Also, cool air may shrink the
respiratory tissues enough to bring relief. Medical interventions usually involve the
administration of corticosteroids and bronchodilators.

Common Cold
● More than 200 viruses are known to cause the common cold. About one half of these
are rhinoviruses, and the others include adenoviruses and coronaviruses. The
symptoms, known to all, are sneezing; acute rhinitis, which is inflammation of the
nasal passageways with copious secretion of watery mucus; tearing of the eyes; and
congestion. The infection may spread from the nose and throat to the sinuses, middle
ear, and lower respiratory tract.
● Cold viruses are mostly spread by airborne virus-filled droplets released by an infected
person’s coughs and sneezes. Frequent hand washing and not touching one’s hands
to any part of the face are good preventive measures.
● The disorder usually resolves in about a week. Because colds are caused by viruses,
antibiotics do not cure them. Rest, fluid intake, symptomatic treatment, and time work
best. The large variety of cold viruses and their frequent mutation have prevented the
development of an effective vaccine.

EMPHYSEMA
● Emphysema is a chronic disease associated with overexpansion and destruction of
the alveoli. Common causes are exposure to cigarette smoke and other forms of
pollution as well as chronic infection. Emphysema is the main disorder included under
the heading of chronic obstructive pulmonary disease (COPD). Other conditions
included in this category are asthma, bronchiectasis, and chronic bronchitis

ASTHMA
● Asthma attacks result from narrowing of the bronchial tubes. This constriction, along
with edema (swelling) of the bronchial linings, inflammation, and mucus accumulation,
results in wheezing, extreme dyspnea (difficulty in breathing), and cyanosis.
● Asthma is most common in children. Although its causes are uncertain, a main factor
is irritation caused by allergy. Heredity may also play a role.
Treatment of asthma includes:
■ removal of allergens
■ administration of bronchodilators to widen the airways
■ administration of corticosteroids to reduce inflammation

PNEUMOCONIOSIS
● Chronic irritation and inflammation caused by dust inhalation is termed
pneumoconiosis. This is an occupational hazard seen mainly in people working in
mining and stone-working industries. Different forms of pneumoconiosis are named
for the specific type of dust inhaled: silicosis (silica or quartz), anthracosis (coal dust),
asbestosis (asbestos fibers).

● Although the term pneumoconiosis is limited to conditions caused by inhalation of

inorganic dust, lung irritation may also result from inhalation of organic dusts, such as
textile or grain dusts.

LUNG CANCER
● Lung cancer is the leading cause of cancer-related deaths in both men and women.
The incidence of lung cancer has increased steadily over the past 50 years, especially
in women. Cigarette smoking is a major risk factor in this as well as other types of
cancer. The most common form of lung cancer is squamous carcinoma, originating in
the lining of the bronchi (bronchogenic). Lung cancer usually cannot be detected early,
and it metastasizes rapidly. The overall long-term survival rate is low.

● Methods used to diagnose lung cancer include radiographic studies, computed

tomography (CT) scans, and sputum examination for cancer cells. Physicians can use
a bronchoscope to examine the airways and to collect tissue samples for study. They
may also take samples by surgical or needle biopsies.

RESPIRATORY DISTRESS SYNDROME

● Respiratory distress syndrome (RDS) of the newborn occurs in premature infants and
is the most common cause of death in this group. It results from a lack of lung
surfactant, which reduces compliance. Acute respiratory distress syndrome (ARDS),
also known as shock lung, may result from trauma, allergic reactions, infection, and
other causes. It involves edema that can lead to respiratory failure and death if
untreated.
CYSTIC FIBROSIS
● Cystic fibrosis (CF) is the most common fatal hereditary disease among white children.
The flawed gene that causes CF affects glandular secretions by altering chloride
transport across cell membranes. Thickening of bronchial secretions leads to infection
and other respiratory disorders. Other mucus-secreting glands, sweat glands, and the
pancreas are also involved, causing electrolyte imbalance and digestive disturbances.

● CF is diagnosed by the increased amounts of sodium and chloride in the sweat.

Geneticists also can identify the gene that causes CF by DNA analysis. There is no
cure at present for CF. Patients are treated to relieve their symptoms, by postural
drainage, aerosol mists, bronchodilators, antibiotics, and mucolytic (mucus-dissolving)
agents.

SUDDEN INFANT DEATH SYNDROME

● Sudden infant death syndrome (SIDS), also called “crib death,” is the unexplained
death of a seemingly healthy infant under 1 year of age. Death usually occurs during
sleep, leaving no signs of its cause. Neither autopsy nor careful investigation of family
history and circumstances of death provides any clues.
● Certain maternal conditions during pregnancy are associated with an increased risk of
SIDS, although none is a sure predictor. These include cigarette smoking, age under
20, low weight gain, anemia, illegal drug use, and reproductive or urinary tract
infections.

Some practices that have reduced the incidence of SIDS are:

■ Place the baby on his or her back (supine) for sleep (“back to sleep”).
■ Keep the baby in a smoke-free environment.
■ Use a firm, flat baby mattress.
■ Don’t overheat the baby.
PLEURAL DISORDERS
● Pleurisy, also called pleuritis, is an inflammation of the pleura, usually associated with
infection. Pain is the common symptom of pleurisy. Because this pain is intensified by
breathing or coughing as the inflamed membranes move, breathing becomes rapid
and shallow. Analgesics and antiinflammatory drugs are used to treat the symptoms of
pleurisy.
● As a result of injury, infection, or weakness in the pleural membrane, substances may
accumulate between the layers of the pleura. When air or gas collects in this space,
the condition is termed pneumothorax. Compression may cause collapse of the lung,
termed atelectasis.
● In pleural effusion,other materials accumulate in the pleural space . Depending on the
substance involved, these are described as empyema (pus), also termed pyothorax;
hemothorax (blood); or hydrothorax (fluid). Causes of these conditions include injury,
infection, heart failure, and pulmonary embolism. Thoracentesis, needle puncture of
the chest to remove fluids, or fusion of the pleural membranes (pleurodesis) may be
required. A chest tube may be inserted to remove air and fluid from the pleural space.

DIAGNOSIS OF RESPIRATORY DISORDERS

● In addition to chest radiographs, CT scans, and magnetic resonance imaging (MRI)
scans, methods for diagnosing respiratory disorders include lung scans,
bronchoscopy, and tests of pleural fluid removed by thoracentesis.
● Arterial blood gases (ABGs) are used to evaluate gas exchange in the lungs by
measuring carbon dioxide, oxygen, bicarbonate, and pH in an arterial blood sample.
● Pulse oximetry is routinely used to measure the oxygen saturation of arterial blood by
means of an oximeter, a simple device placed on a thin part of the body, usually the
finger or the ear.
● Pulmonary function tests are used to assess breathing, usually by means of a
spirometer. They measure the volumes of air that can be moved into or out of the
lungs with different degrees of effort. Often used to monitor treatment in cases of
allergy, asthma, emphysema, and other respiratory conditions, they are also used to
measure progress in smoking cessation.