RESPIRATORY SYSTEM bones increase the mucous membrane

surface of the nasal passages and slightly

The Respiratory system is composed of the upper and
obstruct the air flowing through them
lower respiration tracts. Together, the two tracts are
responsible for VENTILATION. The upper respiratory Paranasal Sinuses
tract, known as the upper airway, warms and filter
- The paranasal sinuses include four pairs of bony
inspired air so that the lower respiratory tract can
cavities that are lined with nasal mucosa and ciliated
accomplish gas exchange or diffusion.
pseudostratified columnar epithelium. These
The role of the respiratory system, is to move air into airspaces are connected by a series of ducts that
the body and remove waste products. Body cells require drain into the nasal cavity. The sinuses are named by
oxygen for respiration. The network of respiratory their location: frontal, ethmoid, sphenoid, and
organs and eventual gas exchange into the blood, maxillary.
enables the oxygen we breathe to reach our body cells. - A prominent function of the sinuses is to serve as a
In turn, carbon dioxide is exhaled. resonating chamber in speech. The sinuses are a
common site of infection.
FUNCTIONAL ANATOMY OF THE RESPIRATORY SYSTEM
Pharynx, Tonsils, and Adenoids
Gas exchanges between the blood and external
environment occur only in the alveoli of the lungs - The pharynx, or throat, is a tubelike structure that
connects the nasal and oral cavities to the larynx. It
• Upper respiratory tract includes passageways from
is divided into three regions: nasal, oral, and
the nose to larynx
laryngeal
• Lower respiratory tract includes passageways from o The nasopharynx is located posterior to the
trachea to alveoli and passageways to the lungs nose and above the soft palate.
purify, humidify, and warm the incoming air o The oropharynx houses the faucial, or
ORGANS OF THE RESPIRATORY SYSTEM palatine, tonsils.
o The laryngopharynx extends from the hyoid
Upper Respiratory Tract bone to the cricoid cartilage. The epiglottis
• Upper airway structures consist of the nose; forms the entrance to the larynx.
paranasal sinuses; pharynx, tonsils, and adenoids; - The adenoids, or pharyngeal tonsils, are located in
larynx; and trachea. the roof of the nasopharynx.
- The tonsils, the adenoids, and other lymphoid tissue
Nose encircle the throat.
- These structures are important links in the chain of
- The nose serves as a passageway for air to pass to
lymph nodes guarding the body from invasion by
and from the lungs. It filters impurities and
organisms entering the nose and the throat.
humidifies and warms the air as it is inhaled.
- The pharynx functions as a passageway for the
o The external portion protrudes from the
respiratory and digestive tracts.
face and is supported by the nasal bones
and cartilage. The anterior nares (nostrils) Larynx
are the external openings of the nasal
cavities. - The larynx, or voice box, is a cartilaginous
o The internal portion of the nose is a hollow epithelium-lined organ that connects the pharynx
cavity separated into the right and left nasal and the trachea and consists of the following:
cavities by a narrow vertical divider, the o Epiglottis: a valve flap of cartilage that
septum. Each nasal cavity is divided into covers the opening to the larynx during
three passageways by the projection of the swallowing
turbinates from the lateral walls. The o Glottis: the opening between the vocal
turbinate bones are also called conchae cords in the larynx
(the name suggested by their shell-like o Thyroid cartilage: the largest of the cartilage
appearance). Because of their curves, these structures; part of it forms the Adam’s apple
 o Cricoid cartilage: the only complete membranes serve to lubricate the thorax and the
cartilaginous ring in the larynx (located lungs and permit smooth motion of the lungs within
below the thyroid cartilage) the thoracic cavity during inspiration and expiration
o Arytenoid cartilages: used in vocal cord
Mediastinum
movement with the thyroid cartilage
o Vocal cords: ligaments controlled by - The mediastinum is in the middle of the thorax,
muscular movements that produce sounds; between the pleural sacs that contain the two lungs.
located in the lumen of the larynx It extends from the sternum to the vertebral column
- Although the major function of the larynx is and contains all of the thoracic tissue outside the
vocalization, it also protects the lower airway from lungs (heart, thymus, the aorta and vena cava, and
foreign substances and facilitates coughing; it is, esophagus)
therefore, sometimes referred to as the “watchdog
of the lungs” Bronchi and Bronchioles

Trachea - There are several divisions of the bronchi within

each lobe of the lung.
- The trachea, or windpipe, is composed of smooth o First are the lobar bronchi (three in the right
muscle with C-shaped rings of cartilage at regular lung and two in the left lung). Lobar bronchi
intervals. The cartilaginous rings are incomplete on divide into segmental bronchi (10 on the
the posterior surface and give firmness to the wall right and 8 on the left); these structures
of the trachea, preventing it from collapsing. The facilitate effective postural drainage in the
trachea serves as the passage between the larynx patient.
and the right and left main stem bronchi, which o Segmental bronchi then divide into
enter the lungs through an opening called the hilus. subsegmental bronchi. These bronchi are
surrounded by connective tissue that
Lower Respiratory Tract
contains arteries, lymphatics, and nerves.
- The lower respiratory tract consists of the lungs, o The subsegmental bronchi then branch into
which contain the bronchial and alveolar structures bronchioles, which have no cartilage in their
needed for gas exchange walls. Their patency depends entirely on the
elastic recoil of the surrounding smooth
Lungs
muscle and on the alveolar pressure. The
- The lungs are paired elastic structures enclosed in bronchioles contain submucosal glands,
the thoracic cage, which is an airtight chamber with which produce mucus that covers the inside
distensible walls lining of the airways.
- Each lung is divided into lobes. The right lung has - The bronchi and bronchioles are also lined with cells
upper, middle, and lower lobes, whereas the left that have surfaces covered with cilia. These cilia
lung consists of upper and lower lobes create a constant whipping motion that propels
- Each lobe is further subdivided into two to five mucus and foreign substances away from the lungs
segments separated by fissures, which are toward the larynx.
extensions of the pleura - The bronchioles branch into terminal bronchioles,
which do not have mucous glands or cilia.
Pleura - Terminal bronchioles become respiratory
- The lungs and wall of the thoracic cavity are lined bronchioles, which are considered to be the
with a serous membrane called the pleura. transitional passageways between the conducting
o The visceral pleura covers the lungs; airways and the gas exchange airways.
o The parietal pleura lines the thoracic cavity, - Up to this point, the conducting airways contain
lateral wall of the mediastinum, diaphragm, about 150 mL of air in the tracheobronchial tree
and inner aspects of the ribs. that does not participate in gas exchange, known as
- The visceral and parietal pleura and the small physiologic dead space. The respiratory bronchioles
amount of pleural fluid between these two then lead into alveolar ducts and sacs and then
 alveoli (see Fig. 17-3). Oxygen and carbon dioxide
exchange takes place in the alveoli.

Alveoli

- The lung is made up of about 300 million alveoli,

constituting a total surface area between 50 and
100 m2 (Norris, 2019). There are three types of
alveolar cells.
o Type I cells account for 95% of the alveolar
surface area and serve as a barrier between
the air and the alveolar surface;
o Type II cells account for only 5% of this area
but are responsible for producing type I
cells and surfactant. Surfactant reduces
surface tension, thereby improving overall
lung function.
▪ Type I and type II cells make up the
alveolar epithelium.
o Alveolar macrophages, the third type of
alveolar cells, are phagocytic cells that
ingest foreign matter and, as a result,
provide an important defense mechanism.

Diaphragm

- The diaphragm is a sheet of muscle which facilitates

inhalation and exhalation. The diaphragm contracts
and moves downwards during inhalation. The
diaphragm relaxes and moves upwards during
exhalation.
Upper airway infections (otherwise known as upper term cold refers to an infectious, acute
respiratory infections [URIs]) are the most common inflammation of the mucous membranes of the
cause of illness and affect most people on occasion. nasal cavity characterized by nasal congestion,
Some infections are acute, with symptoms that last rhinorrhea, sneezing, sore throat, and general
several days; others are chronic, with symptoms that malaise. More broadly, the term refers to an acute
may last for weeks or months or recur. A URI is often URI, whereas terms such as rhinitis, pharyngitis, and
defined as an infection of the mucous membranes of laryngitis distinguish the sites of the symptoms. The
the nose, sinuses, pharynx, upper trachea, or larynx. term is also used when the causative virus is
influenza (the flu). Colds are highly contagious
Rhinitis
because virus is shed for about 2 days before the
- Rhinitis is a group of disorders characterized by symptoms appear and during the first part of the
inflammation and irritation of the mucous symptomatic phase
membranes of the nose.
Rhinosinusitis
- Rhinitis may be acute or chronic, and allergic or
nonallergic. - Rhinosinusitis, formerly called sinusitis, is an
o Allergic rhinitis is further classified as inflammation of the paranasal sinuses and nasal
seasonal or perennial rhinitis and is cavity. The American Academy of Otolaryngology–
commonly associated with exposure to Head and Neck Surgery Foundation (2018;
airborne particles such as dust, dander, or Rosenfeld, Andes, Bhattacharyya, et al., 2015)
plant pollens in people who are allergic to recommends the use of the term rhinosinusitis
these substances. because sinusitis is almost always accompanied by
o Seasonal rhinitis occurs during pollen inflammation of the nasal mucosa. Rhinosinusitis
seasons, and perennial rhinitis occurs affects about 35 million people in the United States
throughout the year. each year and accounts for 16 million office visits
o Drug-induced rhinitis may occur with (Brook, 2018a). Uncomplicated rhinosinusitis occurs
antihypertensive agents, such as without extension of inflammation outside of the
angiotensin-converting enzyme (ACE) paranasal sinuses and nasal cavity. Rhinosinusitis is
inhibitors and beta-blockers; “statins,” such classified by duration of symptoms as acute (less
as atorvastatin and simvastatin; than 4 weeks), subacute (4 to 12 weeks), and
antidepressants and antipsychotics such as chronic (more than 12 weeks). Rhinosinusitis can be
risperidone; aspirin; and some antianxiety caused by a bacterial or viral infection.
medications
Acute Rhinosinusitis

- Acute rhinosinusitis is classified as acute bacterial

rhinosinusitis (ABRS) or acute viral rhinosinusitis
(AVRS). Recurrent acute rhinosinusitis is
characterized by four or more acute episodes of
ABRS per year (Patel & Hwang, 2019) and is
discussed with chronic rhinosinusitis (CRS)

Pharyngitis

- Acute pharyngitis is a sudden painful inflammation

of the pharynx, the back portion of the throat that
Viral Rhinitis (Common Cold) includes the posterior third of the tongue, soft
palate, and tonsils. It is commonly referred to as a
- Viral rhinitis is the most frequent viral infection in sore throat.
the general population (Meneghetti, 2018). The - Because of environmental exposure to viral agents
term common cold often is used when referring to a and poorly ventilated rooms, the incidence of viral
URI that is self-limited and caused by a virus. The pharyngitis peaks during winter and early spring in
 regions that have warm summers and cold winters. the incidence roughly the same between men and
Viral pharyngitis spreads easily in the droplets of women (Flores, 2018). This collection of purulent
coughs and sneezes, as well as from unclean hands exudate between the tonsillar capsule and the
that have been exposed to the contaminated fluids. surrounding tissues, including the soft palate, may
develop after an acute tonsillar infection that
Chronic Pharyngitis
progresses to a local cellulitis and abscess. Several
- Chronic pharyngitis is a persistent inflammation of bacteria are typically implicated in the pathogenesis
the pharynx. It is common in adults who work in of these abscesses, including S. pyogenes, S. aureus,
dusty surroundings, use their voice to excess, suffer Neisseria species, and Corynebacterium species
from chronic cough, or habitually use alcohol and (Flores, 2018; Shah, 2018). In more severe cases, the
tobacco. There are three types of chronic infection can spread over the palate and to the neck
pharyngitis: and chest. Edema can cause airway obstruction,
o Hypertrophic—characterized by general which can be life-threatening and is a medical
thickening and congestion of the pharyngeal emergency. Peritonsillar abscess can be life-
mucous membrane threatening with mediastinitis, intracranial abscess,
o Atrophic—probably a late stage of the first and empyemas resulting from spread of infection.
type (the membrane is thin, whitish, Early detection and aggressive management are
glistening, and at times wrinkled) essential (Flores, 2018).
o Chronic granular—characterized by
Laryngitis
numerous swollen lymph follicles on the
pharyngeal wall - Laryngitis, an inflammation of the larynx, can occur
as a result of voice abuse, exposure to dust,
Tonsillitis and Adenoiditis
chemicals, smoke and other pollutants; or as part of
- The tonsils are composed of lymphatic tissue and a URI. It also may be caused by isolated infection
are situated on each side of the oropharynx. The involving only the vocal cords. Laryngitis can also be
faucial or palatine tonsils and lingual tonsils are associated with gastroesophageal reflux (referred to
located behind the pillars of fauces and tongue, as reflux laryngitis).
respectively. They frequently serve as the site of - Laryngitis is very often caused by the pathogens that
infection (tonsillitis). Acute tonsillitis can be cause the common cold and pharyngitis; the most
confused with pharyngitis. Chronic tonsillitis is less common cause is a virus, and laryngitis is often
common and may be mistaken for other disorders associated with allergic rhinitis or pharyngitis.
such as allergy, asthma, and rhinosinusitis Bacterial invasion may be secondary. The onset of
- The adenoids or pharyngeal tonsils consist of infection may be associated with exposure to
lymphatic tissue near the center of the posterior sudden temperature changes, dietary deficiencies,
wall of the nasopharynx. Infection of the adenoids malnutrition, or an immunosuppressed state. Viral
frequently accompanies acute tonsillitis. Frequently laryngitis is common in the winter and is easily
occurring bacterial pathogens include GABHS, the transmitted to others.
most common organism. The most common viral - Signs of acute laryngitis include hoarseness or
pathogen is Epstein–Barr virus, although aphonia (loss of voice) and severe cough. Chronic
cytomegalovirus may also cause tonsillitis and laryngitis is marked by persistent hoarseness.
adenoiditis. Often thought of as a childhood - The nurse instructs the patient to rest the voice and
disorder, tonsillitis can occur in adults. to maintain a well humidified environment. If
laryngeal secretions are present during acute
Peritonsillar Abscess episodes, expectorant agents are suggested, along
- Peritonsillar abscess (also called quinsy) is the most with a daily fluid intake of 2 to 3 L to thin secretions.
common major suppurative complication of sore The nurse instructs the patient about the
throat accounting for roughly 30% of soft tissue importance of taking prescribed medications,
head and neck abscesses. It most commonly afflicts including proton pump inhibitors, and using
adults between the ages of 20 and 40 years, with
 continuous positive airway therapy at bedtime, if of nasopharyngitis. Frequently, the infection extends
prescribed for OSA. to the nasal sinuses. When rhinosinusitis develops
and the drainage from these cavities is obstructed
Obstructive Sleep Apnea
by deformity or swelling within the nose, pain is
- OSA is a disorder characterized by recurrent experienced in the region of the affected sinus
episodes of upper airway obstruction and a
Fractures of the Nose
reduction in ventilation. It is defined as apnea
(cessation of breathing) during sleep usually caused - The location of the nose makes it susceptible to
by repetitive upper airway obstruction. injury. Nasal fracture is the most common facial
- Risk factors for OSA include obesity, male gender, fracture and the most common fracture in the body
postmenopausal status in women, and advanced (Becker, 2018). Fractures of the nose usually result
age. The major risk factor is obesity; a larger neck from a direct assault. Nasal fractures may affect the
circumference and increased amounts of ascending process of the maxilla and the septum.
peripharyngeal fat narrow and compress the upper The torn mucous membrane results in a nosebleed.
airway. Complications include hematoma, infection,
abscess, and avascular or septic necrosis. However,
Epistaxis
as a rule, serious consequences usually do not occur
- Epistaxis, a hemorrhage from the nose, is caused by
Laryngeal Obstruction
the rupture of tiny, distended vessels in the mucous
membrane of any area of the nose. Rarely does - Obstruction of the larynx because of edema is a
epistaxis originate in the densely vascular tissue serious condition that may be fatal without swift,
over the turbinates. Most commonly, the site is the decisive intervention. The larynx is a stiff box that
anterior septum, where three major blood vessels will not stretch. It contains a narrow space between
enter the nasal cavity: the vocal cords (glottis), through which air must
o (1) the anterior ethmoidal artery on the pass. Swelling of the laryngeal mucous membranes
forward part of the roof (Kiesselbach may close off the opening tightly, leading to life-
plexus), threatening hypoxia or suffocation. Edema of the
o (2) the sphenopalatine artery in the glottis occurs rarely in patients with acute laryngitis,
posterosuperior region, and occasionally in patients with urticaria, and more
o (3) the internal maxillary branches (the frequently in patients with severe inflammation of
plexus of veins located at the back of the the throat, as in scarlet fever. It is an occasional
lateral wall under the inferior turbinate). cause of death in severe anaphylaxis (angioedema)
Several risk factors are associated with
epistaxis Atelectasis

Nasal Obstruction - Atelectasis refers to closure or collapse of alveoli

and often is described in relation to chest x-ray
- The passage of air through the nostrils is frequently findings and clinical signs and symptoms. Atelectasis
obstructed by a deviation of the nasal septum, is one of the most commonly encountered
hypertrophy of the turbinate bones, or the pressure abnormalities seen on a chest x-ray (Stark, 2019).
of nasal polyps. Chronic nasal congestion forces the Atelectasis may be acute or chronic and may cover a
patient to breathe through the mouth, thus broad range of pathophysiologic changes, from
producing dryness of the oral mucosa and microatelectasis (which is not detectable on chest x-
associated problems including persistent dry, ray) to macroatelectasis with loss of segmental,
cracked lips. Patients with chronic nasal congestion lobar, or overall lung volume. The most commonly
often suffer from sleep deprivation due to difficulty described is acute atelectasis, which occurs most
maintaining an adequate airway while lying flat and often in the postoperative setting usually following
during sleep. thoracic and upper abdominal procedures or in
- Persistent nasal obstruction also may lead to chronic people who are immobilized and have a shallow,
infection of the nose and result in frequent episodes monotonous breathing pattern (Conde & Adams,
 2018; Smetana, 2018). Excess secretions or mucus versus community-acquired organisms (Klompas,
plugs may also cause obstruction of airflow and 2019a)
result in atelectasis in an area of the lung. o CAP, a common infectious disease, occurs
Atelectasis also is observed in patients with a either in the community setting or within
chronic airway obstruction that impedes or blocks the first 48 hours after hospitalization or
the flow of air to an area of the lung (e.g., institutionalization.
obstructive atelectasis in the patient with lung o An important distinction of HCAP is that the
cancer that is invading or compressing the airways). causative pathogens are often MDROs
This type of atelectasis is more insidious and slower because of prior contact with a health care
in onset environment. Consequently, identifying this
- Obstructive atelectasis results from any blockage type of pneumonia in areas such as the
that impedes the passage of air to and from the emergency department is crucial. Because
alveoli, reducing alveolar ventilation (Stark, 2019). HCAP is often difficult to treat, initial
Obstructive atelectasis is the most common type antibiotic treatment must not be delayed.
and results from reabsorption of gas (trapped Initial antibiotic treatment of HCAP is often
alveolar air is absorbed into the bloodstream); no different from that for CAP due to the
additional air can enter into the alveoli because of possibility of MDROs
the blockage. As a result, the affected portion of the o HAP develops 48 hours or more after
lung becomes airless and the alveoli collapse. hospitalization and does not appear to be
Causes of atelectasis include foreign body, tumor or incubating at the time of admission. VAP
growth in an airway, altered breathing patterns, can be considered a subtype of HAP, as the
retained secretions, pain, alterations in small airway only differentiating factor is the presence of
function, prolonged supine positioning, increased an ET tube
abdominal pressure, reduced lung volumes due to ▪ The common organisms responsible
musculoskeletal or neurologic disorders, restrictive for HAP include the Enterobacter
defects, and specific surgical procedures (e.g., upper species, Escherichia coli, H.
abdominal, thoracic, or open heart surgery) (Conde influenzae, Klebsiella pneumoniae,
& Adams, 2018). Patients are at high risk for Pseudomonas aeruginosa,
atelectasis postoperatively because of several Acinetobacter species, methicillin-
factors. sensitive or methicillin resistant
Staphylococcus aureus (MRSA), and
Pneumonia
S. pneumoniae.
- Pneumonia is an inflammation of the lung o As noted previously, VAP can be thought of
parenchyma caused by various microorganisms, as a subtype of HAP; however, in such cases,
including bacteria, mycobacteria, fungi, and viruses. the patient has been endotracheally
Pneumonitis is a more general term that describes intubated and has received mechanical
an inflammatory process in the lung tissue that may ventilatory support for at least 48 hours (see
predispose or place the patient at risk for microbial later discussions on ET intubation and
invasion. mechanical ventilation). VAP is a
- Pneumonia can be classified into four types: complication in as many as 27% of patient
community-acquired pneumonia (CAP), health care– who require mechanical ventilation
associated pneumonia (HCAP), hospital-acquired (Gamache, 2019). The incidence of VAP
pneumonia (HAP), and ventilator-associated increases with the duration of mechanical
pneumonia (VAP) (American Thoracic Society & ventilation and the mortality rate is variable,
Infectious Diseases Society of America, 2005; depending upon the complexity of the
Klompas, 2019a). HCAP was conceived as a specific underlying illness.
category in order to identify patients at increased o Aspiration pneumonia refers to the
risk for multidrug-resistant organisms (MDRO) pulmonary consequences resulting from
entry of endogenous or exogenous
 substances into the lower airway. The most The primary infectious agent, M. tuberculosis, is an
common form of aspiration pneumonia is acid-fast aerobic rod that grows slowly and is
bacterial infection from aspiration of sensitive to heat and ultraviolet light.
bacteria that normally reside in the upper Mycobacterium bovis and Mycobacterium avium
airways. Aspiration pneumonia may occur in have rarely been associated with the development
the community or hospital setting. Common of a TB infection.
pathogens are anaerobes, S. aureus, - TB spreads from person to person by airborne
Streptococcus species, and gram-negative transmission. An infected person releases droplet
bacilli nuclei (usually particles 1 to 5 mcm in diameter)
through talking, coughing, sneezing, laughing, or
singing. Larger droplets settle; smaller droplets
remain suspended in the air and are inhaled by a
susceptible person.

Aspiration

- Aspiration is inhalation of foreign material (e.g.,

oropharyngeal or stomach contents) into the lungs.
It is a serious complication that can cause
pneumonia and result in the following clinical
picture: tachycardia, dyspnea, central cyanosis,
hypertension, hypotension, and potentially death. It
can occur when the protective airway reflexes are
decreased or absent due to a variety of factors

Pulmonary Tuberculosis

- Tuberculosis (TB) is an infectious disease that

primarily affects the lung parenchyma. It also may
be transmitted to other parts of the body, including
the meninges, kidneys, bones, and lymph nodes.
The primary infectious agent, M. tuberculosis, is an
acid-fast aerobic rod that grows slowly and is
sensitive to heat and ultraviolet light.
Mycobacterium bovis and Mycobacterium avium
have rarely been associated with the development
of a TB infection.
- M. tuberculosis infects an estimated one third of the
world’s population and remains the leading cause of
death from infectious disease in the world.
- TB spreads from person to person by airborne
transmission. An infected person releases droplet
nuclei (usually particles 1 to 5 mcm in diameter)
through talking, coughing, sneezing, laughing, or
singing. Larger droplets settle; smaller droplets
Pulmonary Tuberculosis remain suspended in the air and are inhaled by a
susceptible person.
- Tuberculosis (TB) is an infectious disease that
primarily affects the lung parenchyma. It also may Pleurisy
be transmitted to other parts of the body, including
- Pleurisy (pleuritis) refers to inflammation of both
the meninges, kidneys, bones, and lymph nodes.
layers of the pleurae (parietal and visceral). Pleurisy
 may develop in conjunction with pneumonia or an characterized by a severe inflammatory process
upper respiratory tract infection, TB, or collagen causing diffuse alveolar damage that results in
disease; after trauma to the chest, pulmonary sudden and progressive pulmonary edema,
infarction, or PE; in patients with primary or increasing bilateral infiltrates on chest x-ray,
metastatic cancer; and after thoracotomy. The hypoxemia unresponsive to oxygen
parietal pleura has nerve endings, and the visceral supplementation regardless of the amount of PEEP,
pleura does not. When the inflamed pleural and the absence of an elevated left atrial pressure
membranes rub together during respiration
Pulmonary Edema (Noncardiogenic)
(intensified on inspiration), the result is severe,
sharp, knifelike pain. - Pulmonary edema is defined as abnormal
accumulation of fluid in the lung tissue, the alveolar
Pleural Effusion
space, or both. It is a severe, life-threatening
- Pleural effusion, a collection of fluid in the pleural condition. Pulmonary edema can be classified as
space, is rarely a primary disease process; it is cardiogenic or noncardiogenic. Noncardiogenic
usually secondary to other diseases. Normally, the pulmonary edema occurs due to damage of the
pleural space contains a small amount of fluid (5 to pulmonary capillary lining. It may be due to direct
15 mL), which acts as a lubricant that allows the injury to the lung (e.g., chest trauma, aspiration, and
pleural surfaces to move without friction (see Fig. smoke inhalation), hematogenous injury to the lung
19-4). Pleural effusion may be a complication of (e.g., sepsis, pancreatitis, multiple transfusions,
heart failure, TB, pneumonia, pulmonary infections cardiopulmonary bypass), or injury plus elevated
(particularly viral infections), nephrotic syndrome, hydrostatic pressures. Management of
connective tissue disease, PE, and neoplastic noncardiogenic pulmonary edema mirrors that of
tumors. The most common malignancy associated cardiogenic pulmonary edema; however, hypoxemia
with a pleural effusion is bronchogenic carcinoma. may persist despite high concentrations of
supplemental oxygen, due to the intrapulmonary
Empyema
shunting of blood.
- An empyema is an accumulation of thick, purulent
Pulmonary Hypertension
fluid within the pleural space, often with fibrin
development and a loculated (walled-off) area - Pulmonary hypertension (PH) is characterized by
where infection is located elevated pulmonary arterial pressure greater than
25 mm Hg at rest and greater than 30 mm Hg with
Acute Respiratory Failure
exercise and secondary right heart ventricular
- Respiratory failure is a sudden and life-threatening failure (Rubin & Hopkins, 2019). It may be suspected
deterioration of the gas exchange function of the in a patient with dyspnea with exertion without
lungs and indicates their failure to provide adequate other clinical manifestations. Unlike systemic blood
oxygenation or ventilation for the blood. Acute pressure, the pulmonary pressures cannot be
respiratory failure is defined as hypoxemia (a measured indirectly.
decrease in arterial oxygen tension [PaO2] to less
than 60 mm Hg) and hypercapnia (an increase in
arterial carbon dioxide tension [PaCO2] to greater Pulmonary Embolism
than 50 mm Hg), with acidosis (an arterial pH of less
- PE refers to the obstruction of the pulmonary artery
than 7.35) (Kaynar, 2018).
or one of its branches by a thrombus (or thrombi)
Acute Respiratory Distress Syndrome that originates somewhere in the venous system or
in the right side of the heart. Deep vein thrombosis
- Acute respiratory distress syndrome (ARDS) can be
(DVT), a related condition, refers to thrombus
thought of as a spectrum of disease, progressing
formation in the deep veins, usually in the calf or
from mild to moderate to its most severe, fulminant
thigh, but sometimes in the arm, especially in
form. Acute lung injury is a term commonly used to
describe mild ARDS. ARDS is a clinical syndrome
 patients with peripherally inserted central catheters. Emphysema
VTE is a term that includes both DVT and PE.
- In emphysema, impaired oxygen and carbon dioxide
Lung Cancer (Bronchogenic Carcinoma) exchange results from destruction of the walls of
overdistended alveoli. Emphysema is a pathologic
- Lung cancer is the leading cancer killer among men
term that describes an abnormal distention of the
and women in the United States, with about 1 out
airspaces beyond the terminal bronchioles and
of 4 cancer deaths from lung cancer; over 135,000
destruction of the walls of the alveoli
deaths were estimated in 2018 (Midthun, 2019).
Each year, more people die of lung cancer than of Bronchiectasis
colon, breast, and prostate cancers combined.
- Bronchiectasis is a chronic, irreversible dilation of
Approximately 228,820 new cases of lung cancer are
the bronchi and bronchioles that results from
diagnosed annually; 13% of new cancers for men
destruction of muscles and elastic connective tissue.
and women involve the lung or bronchus (American
Numerous factors can induce or contribute to the
Cancer Society [ACS], 2019). In approximately 48.5%
development of bronchiectasis. Some of these
of patients with lung cancer, the disease has spread
include recurrent respiratory infections, CF,
to regional lymphatics and other sites by the time of
rheumatic and other systemic diseases, primary
diagnosis. As a result, the long-term survival rate is
ciliary dysfunction, tuberculosis, or immune
low. Overall, the 5-year survival rate is 21.7%
deficiency disorders
Chronic Obstructive Pulmonary Disease - Bronchiectasis, a disease process separate from
COPD, is often a comorbidity with COPD (GOLD,
- Chronic obstructive pulmonary disease (COPD) is a
2019). Bronchiectasis and sinusitis are the major
preventable and treatable slowly progressive
respiratory manifestations of CF (discussed later in
respiratory disease of airflow obstruction involving
this chapter) (Barker et al., 2019)
the airways, pulmonary parenchyma, or both
(Global Initiative for Chronic Obstructive Lung Asthma
Disease [GOLD], 2019). The parenchyma includes
- Asthma is a heterogeneous disease, usually
any form of lung tissue, including bronchioles,
characterized by chronic airway inflammation
bronchi, blood vessels, interstitium, and alveoli. The
(Global Initiative for Asthma [GINA], 2019a). This
airflow limitation or obstruction in COPD is not fully
chronic inflammatory disease of the airways causes
reversible. Most patients with COPD present with
airway hyperresponsiveness, mucosal edema, and
overlapping signs and symptoms of emphysema and
mucus production. This inflammation ultimately
chronic bronchitis, which are two distinct disease
leads to recurrent episodes of asthma symptoms:
processes.
cough, chest tightness, wheezing, and dyspnea
Chronic Bronchitis

- Chronic bronchitis, a disease of the airways, is

Status Asthmaticus
defined as the presence of cough and sputum
production for at least 3 months in each of 2 - An asthma exacerbation can range from mild to
consecutive years. Although chronic bronchitis is a severe with potential respiratory arrest (GINA,
clinically and epidemiologically useful term, it does 2019a). The term status asthmaticus is sometimes
not reflect the major impact of airflow limitation on used to describe rapid onset, severe, and persistent
morbidity and mortality in COPD (GOLD, 2019). In asthma that does not respond to conventional
many cases, smoke or other environmental therapy. The attacks can occur with little or no
pollutants irritate the airways, resulting in warning and can progress rapidly to asphyxiation.
inflammation and hypersecretion of mucus. Infection, anxiety, inhaler abuse, dehydration,
Constant irritation causes the mucus-secreting increased adrenergic blockage, and nonspecific
glands and goblet cells to increase in number, irritants may contribute to these episodes. An acute
leading to increased mucus production. Mucus episode may be precipitated by hypersensitivity to
plugging of the airway reduces ciliary function.
 medications, such as aspirin, beta-blockers, and
nonsteroidal anti-inflammatory drugs (NSAIDs).

Cystic Fibrosis

- CF is the most common fatal autosomal recessive

disease among Caucasians. It is less frequently
found among Hispanic, Asian, and African
Americans. A person must inherit a defective copy
of the CF gene (one from each parent) to have CF.
- CF is caused by mutations or dysfunction in the
protein cystic fibrosis transmembrane conductance
regulator (CFTR), which normally transports chloride
ions across epithelial cell membranes. Gene
mutations affect transport of these ions, leading to
CF, which is characterized by thick, viscous
secretions in the lungs, pancreas, liver, intestine,
and reproductive tract as well as increased salt
content in sweat gland secretions. The most
common mutation is ΔF508; however, researchers
have identified more than 1700 mutations of the
disease (CFF, 2019a). The numerous mutations of
the CFTR gene create multiple variations in the
presentation and progression of the disease