ANATOMY AND PHYSIOLOGY RESPIRATORY SYSTEM Respiration has two meanings in biology. At the cellular level it re!

e!ers to the O" re#uiring chemical reactions that ta$e place in the mitochon%ria an% are the chie! source o! energy in the eu$aryotic cells. At the level o! the whole organism it %esignates the process o! ta$ing In O" !rom the environment an% returning &O" to it.

O" consumptions is %irectly relate% to energy e'pen%iture. Energy re#uirements are usually calculate% by measuring O" inta$e o! &O" release. Energy e'pen%iture at rest is $nown as basal metabolism. (unctional Anatomy o! the Respiratory System The organs o! the respiratory system inclu%e the nose pharyn' laryn' trachea bronchi an% their smaller branches an% the lungs which contain the alveoli or terminal air sacs. Since gas e'changes with the bloo% happen only in the alveoli the other respiratory system structures are really )ust con%ucting passageways that allow air to reach !or lungs. *owever these passageways have another important )ob. They puri!y humi%i!y an% warm incoming air. Thus the air !inally reaching the lungs has many !ewer irritants +such as %ust or bacteria, than when it entere% the system.

The -ose The nose is the only e'ternally visible part o! the respiratory system. .uring breathing air enters the nose by passing through the nostrils or e'ternal nares. The interior the nose consists o! the nasal cavity %ivi%e% by a mi%line nasal septum. It has three mucosa/covere% pro)ections or loves calle% conchae which greatly increase the sur!ace area o! the mucosa e'pose% to the air an% increase the air turbulence in the nasal cavity. It is separate% !rom the oral cavity below by a partition the palate. Anteriorly where the palate is supporte% by bone is the har% palate0 the unsupporte% posterior part is the so!t palate. It is surroun%e% by a ring o! paranasal sinuses locate% in the !rontal sphenoi% ethmoi% an% ma'illary bones which lighten the s$ull act as resonance chambers !or speech an% pro%uce mucus which %rains into the nasal cavities. Pharyn' The pharyn' +throat, is a muscular passageway about 12cm long that vaguely resembles a short length o! re% gar%en hose. It serves as a common passageway !or !oo% an% air an% is continuous with the nasal cavity anteriorly via the internal nares. Air enters the nasopharyn' !rom the nasal cavity an% then %escen%s through the oropharyn' an% laryngopharyn' to enter the laryn' below. It consists o! pharyngotympanic tubes which %rain the mi%%le ear open into the nasopharyn'. &lusters o! lymphatic tissue calle% tonsils are also !oun% in the laryn'. The pharyngeal tonsil +a%enoi%, is o3locate% high in the nasopharyn'. The palatine tonsils are in the oropharyn' at the en% o! the so!t palate0 the lingual tonsils are at the base o! the tongue. These tonsils protect the bo%y !rom in!ection 4aryn' The laryn' +voice bo', routes air an% !oo% into the proper channels an% plays a role in speech. It is !orme% by eight rigi% hyaline cartilages an% a spoon/shape% !lap o! elastic cartilage the epiglottis. The epiglottis protects the superior opening o! the laryn'. I! anything other than the air enters the laryn' a cough re!le' is triggere% to e'pel the substance an% prevent it !rom continuing into the lungs. Part o! the mucous membrane o! the laryn' !orms a pair o! !ol%s the vocal !ol%s or true vocal cor%s which vibrate with e'pelle% air. It then allows us to spea$. Trachea Air enters trachea +win%pipe, !rom the laryn' then travels %own its length +15/1"cm, to the level o! the !i!th thoracic vertebra which is appro'imately mi%chest. It is !airly rigi% because its walls are rein!orce% with &/shape% rings o! hyaline cartilage which serve a %ouble purpose. The open parts o! the rings abut the esophagus an% allow it to e'pan% anteriorly when we swallow a large piece o! !oo%. The soli% portions support the trachea walls an% $eep it patent or open in spite o! the pressure changes that occur %uring breathing. Main 6ronchi The right an% le!t main +primary, bronchi are !orme% by the %ivision o! the trachea. Each main bronchus runs obli#uely be!ore it plunges into the me%ial %epression +bilus, o! the lung on

its own si%e. The right main bronchus is wi%er shorter an% straighter than the le!t. &onse#uently it is more common site !or an inhale% !oreign ob)ect to become lo%ge%. 6y the time incoming air reaches the bronchi it is warm cleanse% o! most impurities an% well humi%i!ie%. The smaller sub%ivisions o! the main bronchi within the lungs are %irect routes to the air sacs. 4ungs The paire% lungs are !airly large organs. They occupy the entire thoracic cavity e'cept !or the most central area the me%iastinum which houses the heart great bloo% vessels bronchi esophagus an% other organs. The narrow superior portion o! each lung the ape' is locate% )ust %eep to the clavicle. The broa% lung area resting on the %iaphragm is the base. Each lung is %ivi%e% into loves by !issures0 the le!t lung has two lobes an% the right lung has three. The sur!ace o! each lungs is covere% with a visceral serosa calle% the pulmonary or visceral pleura an% the walls o! the thoracic cavity are line% by the parietal pleura. The pleural membranes pro%uce pleural !lui% a slippery serous secretion which allows the lungs to gli%e easily over the thora' wall %uring breathing movements an% causes the two pleural layers to cling together. A!ter the primary bronchi enter the lungs they sub%ivi%e into smaller an% smaller braches +secon%ary an% tertiary bronchi an% so on, !inally en%ing in the smallest o! the con%ucting passageways the bronchioles. The terminal bronchioles lea% into respiratory 7one structures even smaller con%uits that eventually terminate in alveoli. The Respiratory Membrane The walls o! the alveoli are compose% largely o! a single thin layer o! s#uamous epithelial cells. Alveolar pores connect neighboring air sacs an% provi%e alternate routes !or air to reach alveoli whose !ee%er bronchioles have been clogge% by mucus or otherwise covere% with a 8cobweb9 o! pulmonary capillaries. The alveolar an% capillary walls construct the respiratory membrane +air/bloo% barrier, which has gas +air, !lowing past on one si%e an% bloo% !lowing past on the other. The gas e'changes occur by simple %i!!usion through the respiratory membrane : o'ygen passing !rom the alveolar air into the capillary bloo% an% carbon %io'i%e leaving the bloo% to enter the gas/!ille% alveoli. The !inal line o! %e!ense !or the respiratory system is in the alveoli. The cuboi%al cells pro%uce a lipi% molecule calle% sur!actant which coats the gas/e'pose% alveolar sur!aces an% is very important in lung !unction. Respiratory Physiology The ma)or !unction o! the respiratory system is to supply the bo%y with o'ygen an% to %ispose carbon %io'i%e. There are !our events that must occur; 1. Pulmonary ventilation +breathing, : Air moves in an% out o! the lungs wherein gases in the alveoli are continuously change% an% re!reshe%. ". E'ternal respiration : <as e'change between the bloo% an% the bo%y e'terior. 2. Respiratory gas transport : O'ygen an% carbon %io'i%e are transporte% to an% !rom the lungs an% tissue cells o! the bo%y via the bloo%stream.

=. Internal respiration : <as e'changes are occurring between the bloo% an% cells insi%e the bo%y. Mechanics o! 6reathing 6reathing +pulmonary ventilation, is a completely mechanical process that %epen%s on volume changes occurring in the thoracic cavity. It involves two phases inspiration +inhalation, where air is !lowing into the lungs through the contraction o! the %iaphragm an% e'ternal intercostals which there!ore increases the si7e o! the thoracic cavity an% e'piration +e'halation, where air leaves the lungs causing the inspiratory muscles to rela' an% resume their initial resting length that %escen%s the rib cage an% recoils the lungs.

PATHOPHYSIOLOGY P-E>MO-IA The term pneumonia %escribes in!lammation o! parenchymal structures o! the lung such as the alveoli an% the bronchioles. Although antibiotics have signi!icantly re%uce% the mortality rate !rom pneumonias these %iseases remain the si'th lea%ing cause o! %eath in the >nite% States an% an important imme%iate cause o! %eath in the el%erly an% persons with %ebilitating %iseases. Etiologic agents inclu%e in!ectious an% nonin!ectious agents. &lassi!ication Pneumonias can be classi!ie% accor%ing to the type o! agent +typical or atypical, causing the in!ection %istribution o! the in!ection +lobar pneumonia or bronchopneumonia, an% setting +community or hospital, in which it occurs. Typical pneumonias result !rom in!ection by bacteria that multiply e'tracellularly in the alveoli an% cause in!lammation an% e'u%ation o! !lui% into the air/!ille% spaces o! the alveoli. Atypical pneumonias are cause% by viral an% mycoplasma in!ections that involve the alveolar septum an% interstitium o!t the lung. They pro%uce less stri$ing symptoms an% physical !in%ings than bacterial pneumonia0 there is a lac$ o! alveolar in!iltration an% purulent sputum leu$ocytosis an% lobar consoli%ation in the ra%iograph. Acute bacterial pneumonias can be classi!ie% as lobar pneumonia or bronchopneumonia base% on their anatomic pattern o! %istribution. In general lobar pneumonia re!ers to consoli%ation o! a part or all o! a lung lobe an% bronchopneumonia signi!ies a patchy consoli%ation involving more than one lobe. 6ecause o! the overlap in the symptomatology an% changing spectrums o! in!ectious microorganisms involve% pneumonias are increasingly being classi!ie% accor%ing to the setting +community/ac#uire% or hospital/ac#uire%, in which they occur.

&OMM>-ITY/A&?>IRE. P-E>MO-IA It is use% to %escribe in!ections !rom organisms !oun% in the community rather than in the hospital or nursing home. It is %e!ine% as an in!ection that begins outsi%e the hospital or is %iagnose% within =@ hours a!ter a%mission to the hospital in a person who has not resi%e% in a long/term care !acility !or 1= %ays or more be!ore a%mission. &ommunity/ac#uire% pneumonias may be !urther categori7e% accor%ing to ris$ o! morality an% nee% !or hospitali7ation base% on age presence o! coe'isting %isease an% severity o! illness as %etermine% by physical e'amination laboratory an% ra%iologic !in%ings. &ommunity/ac#uire% pneumonias may either be bacterial or viral. The most common cause is S. pneumoniae. Other common pathogens inclu%e H. influenza, S. aureus gram/ negative bacilli. 4ess common agents are M. catarrbalis. &ommon viral causes inclu%e the in!luen7a virus respiratory syncytial virus a%enovirus an% parain!luen7a virus. The metho%s use% in %iagnosing %epen% on age coe'isting health problems an% the severity o! illness. In persons younger than AB years o! age an% without coe'isting %isease the %iagnosis is usually base% on history an% physical e'amination chest ra%iographs an% $nowle%ge o! the microorganisms currently causing in!ections in the community. Sputum specimens may be obtaine% !or staining proce%ures an% culture. 6loo% culture may be %one !or person re#uiring hospitali7ation.

*OSPITA4/A&?>IRE. P-E>MO-IA Also terme% as nosocomial is %e!ine% as lower respiratory tract in!ection that was not present or incubating on a%mission to the hospital. >sually in!ections occurring =@ hours or more a!ter a%mission are consi%ere% hospital/ac#uire%. C5D o! in!ections are bacterial. The organisms are those present in the hospital environment an% inclu%e Pseudomonas aeruginosa, S. aureus, Enterobacteria species Klebsiella species Escherichia coli, an% Serratia. Many o! these have ac#uire% antibiotic resistance an% are more %i!!icult to treat.

P-E>MO-IA Eiral In!ection In!luen7a 6acterial In!ection A%enovirus Staphylococcus Respiratory syncytial virus Streptococcus Pneumococcus In!lammation o! pulmonary parenchyma 4obar Pneumonia Engorgement with e!!usion o! bloo% an% serum into alveoli in one or more lobes +Stage I, 4obe airless an% alveoli contain !ibrin serum R6&s neutrophils +Stage II, 4ove larger with !ibrin in alveoli an% %ecrease% cellular elements an% bacteria +Stage III, >sually Pneumococca 6ronchopneumonia Mucopurulent e'u%ate in terminal bronchioles &logging o! bronchioles -ecrosis an% sloughing o! bronchial mucous membranes (ormation o! peribronchial abscesses an% pneumatoceles >sually Staphylococcal In!lammation o! walls o! alveoli bronchi an% bronchioles >sually viral or treptococcal Pleural e!!usion Empyema

(ungal In!ection Pseu%omonas &an%i%a Interstitial Pneumonia

Resolution with treatment

Resolution with treatment

Pleural e!!usion Pleurisy Empyema

Resolution Pneumothrora' with treatment Empyema