Chapter 5

Respiratory
Function

Summer 2018

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 Learning Objectives

• Respiratory System – Divisions and Functions

• Gas exchange and transportation
• Lung compliance
• Role in pH balance
• Upper respiratory tract infections
• Lower respiratory tract infections
• Alterations in ventilation

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https://www.pinterest.com/pin/34480753371180387/
 Respiratory System
• Two Divisions
– Air-conducting – delivers air
• Includes the nose, mouth, trachea,
bronchi, and bronchioles
– Gas exchange – swaps gases
between air and blood
• Includes alveoli and capillaries

• Mucus, cilia, and immune cells protect the

system from harmful inhaled particles.
• Capillaries in the nose warms and humidifies
the air to protect system from drying and
damage from cold.
 Gas Exchange

• Requires adequate ventilation and perfusion

o Ventilation/perfusion ratio (VQ ratio)
o Normal ventilation = 4L per minute
o Normal perfusion = 5L per minute
• Normal V/Q ratio = 0.8
• Dependent on alveolar and capillary surface area and thickness

Gas Transportation

• Gases (O2 and CO2) carried by hemoglobin

• Once to the site, hemoglobin must be able to release the gases
– Affected by a variety of things such as pH and temperature

https://www.youtube.com/watch?v=lr5dDmTASos
3:25 min 5
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http://www.slideshare.net/MrJewett/respiratory-system-jewett
 Lung Compliance
• Elasticity and recoil are vital
• Surfactant is a lipoprotein that
– Has a detergent quality
– Produces alveoli surface tension to
prevent collapse
• The respiratory system is a negative
pressure system
Breathing
• Largely involuntary
• Controlled by the medulla oblongata
• Chemoreceptors
• Stretch receptors
• Inspiration – inhaling
• Expiration – exhaling
• Diaphragm
• Intercostal muscles Muscles that help in respiration 7
 Pulmonary Function Tests

• Lung volumes
• Tidal volume – amount of air moved in and out
with a normal breath; ~500ml
• Minute respiratory volume – amount of air
moved in and out in one minute; ~ 6L
• Inspiratory reserve volume – maximum amount
of air that can be inhaled over tidal volume; 2-3L
• Expiratory reserve volume - maximum amount
of air that can be exhaled over tidal volume; 1-
1.5L
• Vital capacity – sum of the tidal volumes and the
reserves
• Residual volume – amount of air left in the lung
after forced expiration; 1-1.5L

https://www.nhlbi.nih.gov/health/health-topics/topics/copd/diagnosis
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 Role in pH Balance
• Carbon dioxide is one of the body’s acids
• Lungs alter the rate and depth of breathing to regulate pH
• Increased rate of breathing expels more carbon dioxide and
raises pH
• Decreased rate of breathing retains more carbon dioxide and
lowers pH

Understanding Respiratory Conditions

• Alterations resulting in reduced ventilation

• Alterations resulting in reduced perfusion
• Alterations resulting in impaired gas exchange
• Alterations resulting in ineffective airway clearance
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 Upper Respiratory Lower Respiratory
Tract Infections Tract Infections
• Infectious rhinitis (common cold) • Pneumonia
• Sinusitis • Tuberculosis
• Laryngitis
• Croup
• Acute Bronchitis
• Influenza
Alterations in Ventilation
• Asthma
• COPD – Chronic Bronchitis and Emphysema
• Lung Cancer
• Pleural Effusion
• Acute Respiratory Distress Syndrome

Alterations in Ventilation & Perfusion

• Atelectasis
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Upper Respiratory Tract
Infections

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 Infectious Rhinitis

• Common cold
• Usually caused by the rhinovirus
• Highly contagious
• May also see a secondary
bacterial infection
• Incubation period = 2-3 days
• Manifestations: sneezing, nasal
congestion, nasal discharge,
sore throat, nonproductive
cough, malaise, myalgia, low-
grade fever, hoarseness,
headache, and chills

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 Sinusitis
• Inflammation of the sinus cavities
• Causes: virus, bacteria, and fungus
• Exudate collects and blocks the sinus
cavities
• Manifestations: facial pain, nasal
congestion, fever, and sore throat
Laryngitis
• Inflammation of the larynx
• Usually self-limiting
• Causes: infection, increased upper respiratory exudate, and
overuse
• Manifestations: hoarseness, weak voice or voice loss, tickling
sensation and raw feeling in the throat, sore throat, dry cough, and
difficulty breathing 13
 Laryngotracheobronchitis
• Commonly called “Croup”
• Common viral infection in children, usually
parainfluenza viruses and adenoviruses
• Larynx and surrounding area swell, leading
to airway narrowing, obstruction, and
respiratory failure
• Manifestations: nasal congestion, seal-like
barking cough, hoarseness, inspiratory
https://www.youtube.com/watch?v=jYZ0YZYjbrY
http://www.news-medical.net/health/Croup-Acute-Laryngotracheobronchitis.aspx

stridor, dyspnea, anxiety, and cyanosis Croup cough

Acute Bronchitis
• Inflammation of the tracheobronchial tree or
large bronchi
• Causes: viruses, bacterial, irritant inhalation,
and allergic reactions
• Manifestations: productive and nonproductive
cough, dyspnea, wheezing, low-grade fever,
pharyngitis, malaise, and chest discomfort http://www.webmd.com/lung/acute-bronchitis
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 Influenza
• Commonly called “Flu” – caused by influenza virus
• Viral infection that may affect the upper and lower respiratory
tract
• Highly-adaptive virus
• US flu season between November and March
• Incubation period of 1–4 days
• Can cause significant problems with children, elderly, and those
who are immune compromised
• Manifestations: fever, headache, chills, dry cough, body aches,
nasal congestion, sore throat, sweating, and malaise
• Prevention of transmission: handwashing, avoiding crowds, and
vaccination

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http://www.medicinenet.com/influenza/article.htm
Lower Respiratory Tract
Infections

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 Pneumonia

• Inflammatory condition of the lung

• Causes: infectious agents, injurious agents or events, and
pulmonary secretion stasis
• Viral
• Usually mild
• Can lead to secondary bacterial
pneumonia
• Bacterial
• More common than viral
• Most often by Streptococcus pneumoniae

https://www.youtube.com/watch?v=aKduNgfePLU 4:44 min

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http://www.dreamstime.com/stock-image-pneumonia-image23933611
 types of Pneumonia

• Aspiration pneumonia
o Causes: impaired gag reflex, improper
lower esophageal sphincter closure,
inappropriate tube-feeding placement
• Lobar pneumonia
o Confined to a single lobe
• Bronchopneumonia
o Most frequent type
o A patchy pneumonia throughout several
lobes

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https://www.pinterest.com/pin/138274651034149281/
 Pneumonia

• Interstitial pneumonia or atypical

o Occurs in the areas between the alveoli
o Routinely caused by viruses or by uncommon bacteria
• Nosocomial pneumonia
o Develops more than 48 hours after a hospital admission
• Community-acquired pneumonia
o Acquired outside the hospital or healthcare setting

• Complications: septicemia, pulmonary edema, lung abscess, and

acute respiratory distress syndrome

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 Tuberculosis

• Caused by the bacillus, Mycobacterium tuberculosis

• Resistant strains have developed in those immune compromised
• Most frequently occurs in the lungs, but can spread to other organs
• Carried by airborne droplets

https://www.youtube.com/watch?v=IGZLkRN76Dc
2:55 min
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 Tuberculosis
Ghon Complex

• Primary infection
• When bacillus first enters the body
• Macrophages engulf the microbe causing a local
inflammatory response
• Some bacilli travel to the lymph nodes, activating
the type IV hypersensitivity reaction

• Caseous necrosis and Ghon complexes

develops
• Bacilli can remain dormant for years
• Usually asymptomatic

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http://medical-dictionary.thefreedictionary.com/tuberculosis
 Tuberculosis
• Secondary infection
• Reactivation of dormant bacilli
• Can spread to other organs
• Symptoms usually develop
• Manifestations: productive cough, hemoptysis, night sweats, fever,
chills, fatigue, unexplained weight loss, anorexia, and symptoms
depending other organ involvement
• Diagnosis: skin test (Mantoux), Chest X-ray, computerized
tomography , and sputum culture
• Treatment: antimicrobial combination therapy for at least 6 months
• Prevention: vaccination, respiratory precautions, adequate
ventilation, and appropriate isolation

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Alterations in Ventilation

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 Asthma
• Chronic disorder that results in intermittent, reversible airway
obstruction
• Characterized by acute airway inflammation, bronchoconstriction,
bronchospasm, bronchiole edema, and mucus production
• Most common chronic illness in children in the United States.
• A variety of triggers from infections to smoke

https://www.youtube.com/watch?v=4aK76DoxKGk 3:35 min 24

 Types of Asthma
• Extrinsic asthma
IgE and airway Mast cell Inflammatory
inflammation destruction mediator release

o Mediator release cause bronchoconstriction, increased capillary

permeability, and mucus production
o Generally presents in childhood or adolescence
o Triggers: allergens such as food, pollen, dust, and medications

• Intrinsic asthma
o Not an allergic reaction
o Usually presents after age 35 years
o Triggers: upper respiratory infections, air pollution, emotional stress,
smoke, exercise, and cold exposure
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 Types of Asthma
• Nocturnal asthma
o Usually occurs between 3:00 and 7:00 a.m.
o May be related to circadian rhythms – at night, cortisol and
epinephrine levels decrease, while histamine levels increase,
leading to bronchoconstriction
• Exercise-induced asthma
o Usually occurs 10–15 minutes after activity
o Symptoms can linger for an hour
o May be a compensatory mechanism to warm and moisten the
airways
o Followed by a refractory period begins within 30 minutes and
can last 90 minutes

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 Types of Asthma
• Occupational asthma
o Caused by a reaction to substances at work
o Symptoms develop over time, worsening with each exposure
and improving when away from work

• Drug-induced asthma
o Frequently caused by aspirin – prevents the conversion of
prostaglandins, which stimulate leukotriene release, a powerful
bronchoconstrictor
o Can be fatal
o Reactions can be delayed up to 12 hours after drug ingestion

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 Stages of an Asthma Attack

• Stage one
o Related to bronchospasms, and it is usually signaled by
coughing
o Peaking within 15 to 30 minutes, inflammatory mediators
responsible include leukotrienes, histamine, and some
interleukins

• Stage two
o Peaks within 6 hours of symptom onset
o Result of airway edema and mucus production
o The alveolar hyperinflation causes air trapping
o Bronchospasm, smooth muscle contraction, inflammation,
and mucus production combine to narrow the airways
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https://biology-forums.com/index.php?action=gallery;sa=view;id=9261
 Asthma
• Manifestations: wheezing, shortness of breath, dyspnea, chest
tightness, cough, tachypnea, and anxiety
Status Asthmaticus
• Life-threatening, prolonged asthma attack that does not respond
to usual treatment
• Can lead to respiratory alkalosis and respiratory failure quickly

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http://pendidikanpesakit.myhealth.gov.my/en/doctors-diagnose-asthma-children-sign/
 Chronic Obstructive Pulmonary Disease
(COPD)
• Debilitating chronic disorders characterized by irreversible,
progressive tissue degeneration and airway obstruction
• Severe hypoxia and hypercapnia can lead to respiratory failure
• Oxygen begins to drive breathing
• Can also lead to cor pulmonale – Right heart failure due to lung
disease
• Causes: smoking, pollution, chemical irritants, and genetic
mutation

https://www.youtube.com/watch?v=2nBPqSiLg5E 4:00
min 30
 Chronic Obstructive Pulmonary Diseases
https://www.youtube.com/watch?v=15DBE6giDUA 1:41 min a patient's perspective
• Often asymptomatic early or masked
by smoking
• Two main conditions:

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 Chronic Bronchitis
• “Blue bloaters”
• Characterized by inflammation of the bronchi, a productive cough,
and excessive mucus production
• Complications: frequent respiratory infections and respiratory
failure
• Manifestations: hypoventilation, hypoxemia, cyanosis,
hypercapnia, polycythemia, clubbing of fingers, dyspnea at rest,
wheezing, edema, weight gain, malaise, chest pain, and fever
• Diagnosis: history (persistent, productive cough for at least 3
months in a year for 2 consecutive years), physical examination,
chest X-ray, pulmonary function tests, arterial blood gases, and
complete blood counts

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 Emphysem
a
https://www.youtube.com/watch?v=Ns_B7gl-uLk 1:55 min

• “Pink puffers”
• Destruction of the alveolar walls leads to large,
permanently inflated alveoli
• Enzyme necessary for lung remodeling is
deficient
• Loss of elastic recoil and hyperinflation of the
alveoli, leading to air trapping https://www.drugs.com/health-guide/emphysema.html

• Causes: genetic predisposition and smoking

• Manifestations: dyspnea upon exertion,

diminished breath sounds, wheezing, chest
tightness, tachypnea, hypoxia, hypercapnia,
activity intolerance, anorexia, and malaise

http://www.webmd.com/lung/copd/living-wit
h-copd-17/rm-quiz-myths-facts-copd
WebMD 14 question quiz 33
 Lung Cancer
• Third most common cancer
• May occur as a primary or secondary tumor
• Deadliest of the cancer in men and women
Medscape800 × 600Search by image

• Smoking is the most significant risk factor, either first-

hand or second-hand
Types of Lung Cancer
• Small cell carcinoma
o AKA oat cell carcinoma - Less frequent
o Occurs almost exclusively in heavy smokers
• Non–small cell carcinoma
o AKA bronchogenic carcinoma
o Most common type of malignant lung cancer - very aggressive
o Several subgroups—squamous cell carcinoma, adenocarcinoma,
and bronchioalveolar carcinoma 34
 Lung Cancer
• Complications: airway obstruction, lung tissue inflammation, fluid
accumulation, and paraneoplastic syndrome
• Manifestations: persistent cough or a change in usual cough, dyspnea,
hemoptysis, frequent respiratory infections, chest pain, hoarseness,
weight loss, anemia, fatigue, and other symptoms specific to site of
metastasis
• Treatment:
o Usually palliative
o Includes: chemotherapy, radiation,
and surgery

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 Pleural Effusion
• Excess fluid in the pleural cavity
• Fluid may include exudates, transudate, blood, and
pus
• Can impair breathing
• May also see pleurisy – inflammation of the pleural
membranes
• Manifestations: dyspnea, chest pain, tachypnea,
tracheal deviation, absent lung sounds and dullness
over affected area, tachycardia, and pleural friction
rub
• Diagnosis: history, physical examination, chest
X-ray, computed tomography, arterial blood
gases, complete blood gases, and
thoracentesis
• Treatment: thoracentesis, chest drainage tube,
and antibiotics 36
https://www.pinterest.com/explore/pulmonary-edema/
 Pneumothorax
• Air in the pleural cavity
• Can lung to collapse
• Risk factors: smoking and history of lung
disease or previous pneumothorax

• Clinical manifestations : sudden chest pain over the affected lung,

chest tightness, dyspnea, tachypnea, decreased breath sounds over
the affected area, asymmetrical chest movement, trachea and
mediastinum deviation toward the unaffected side, anxiety,
tachycardia, pallor, hypotension
Types https://www.youtube.com/watch?v=i-sZzZ4TMnY 2:05 min

• Spontaneous pneumothorax - when air enters the pleural cavity

from an opening in the internal airways (e.g., smoking marijuana,
emphysema, pneumonia, cystic fibrosis, or lung cancer).
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 Pneumothorax
• Traumatic pneumothorax - any blunt trauma (e.g., vehicle air bag
deployment) or penetrating injury (e.g., knife or gunshot wounds) to the
chest.
• Tension pneumothorax - most serious type of pneumothorax
o Occurs when the pressure in the pleural space is greater than the
atmospheric pressure.
o The increased pressure arises due to trapped air in the pleural space or
entering air from a positive-pressure mechanical ventilator.
o Tension pneumothorax progresses rapidly and is fatal if not treated quickly.

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 Acute Respiratory Distress Syndrome (ARDS)
Lung < 48 hours widespread inflammation Respiratory
Injury in the lungs failure
• Results from fluid accumulation in the alveoli due to a systemic or pulmonary event
that is not cardiac in origin
• Causes: shock, burns, aspiration, and smoke inhalation acute hypoxemia

• Complications: respiratory and metabolic

acidosis, pulmonary fibrosis, pneumothorax,
bacterial infections, decreased lung function,
muscle wasting, memory, cognitive, and
emotional issues, and death
• Manifestations: dyspnea, labored and shallow
respirations, rales, productive cough with frothy
sputum, hypoxia, cyanosis, fever, hypotension,
tachycardia, restlessness, confusion, lethargy,
and anxiety

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http://www.medindia.net/patients/patientinfo/respiratory-distress-syndrome.htm
 Atelectasis(
A for alveoli)
• Collapse of the alveoli
• Causes: surfactant deficiencies, bronchus obstruction, lung
tissue compression, increased surface tension, and lung fibrosis
• Ventilation and perfusion problem
• Manifestations: diminished breath sounds, dyspnea, tachypnea,
asymmetrical lung movement, anxiety, restlessness, tracheal
deviation, and tachycardia

https://blausen.com/en-gb/video/atelectasis/
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1:27 min