I.

INTRODUCTION

Equipping oneself with knowledge about various kinds of diseases is a necessity in

nursing profession, as this may help enhance the nurse’s ability to promote, restore and

maintain health and even prevent occurrence of illness. Each case is unique in its own

way though they all possess a particular characteristic, which is to impair a person’s

health. Nurses should be knowledgeable in terms of preventing and giving proper

intervention with those people who have a specific disease. And one of many different

ways in gaining more knowledge is through constant learning and discovery. This case

study is a tool in expanding knowledge about a particular disease that will help us in

dealing with our future patients.

You would think that in the light of modern medical treatment and wide availability

of antibiotics, Pneumonia would no longer kill us, right? Wrong! For children, this

remains to be a major killer, either as a sole disease beginning with a respiratory

infection, or as a complication of measles. Based on DOH (Department of Health) in the

Philippines, pneumonia ranked 5th in the leading cause of mortality as of 2006. With

these, it is better to understand what really the meaning of this disease is.

1. Description of the disease

Pneumonia is basically the infection of the lung which is considered to be a sterile

field. This is caused by bacteria, virus and other microorganisms that invade the lungs but

most often, pneumonia is caused by bacteria particularly the Streptococcus pneumoniae.

Another is that, it is an inflammatory process in the lung parenchyma associated with a

marked increase in interstitial and alveolar fluid. This inflammatory process is now

1
treated with antibiotic therapy which led to the perception that this condition is no longer

a major problem. In spite of this, pneumonia and influenza are currently the sixth most

common cause of death for all ages and one of the most common causes in adult. This

condition is also seen among individuals who have weak immune system.

As the microorganisms penetrate and invade the lungs, in this condition, the

following manifestations may be evident- there is coughing, fever and chills are also

evident in relation to the inflammatory process, sweats, pleuritic chest pain, sputum

production, hemoptysis in severe cases, dyspnea, headache and fatigue may also be

present.

Lung diseases have always been a major concern in the health field. In an article

in the Jan. 15 issue of the American Journal of Respiratory Critical Care Medicine, there

has been this research that a serious life-threatening form of pulmonary fibrosis called

idiopathic pulmonary fibrosis. There are certain conditions associated with lung diseases

that are barely understood. This diagnosis of the diseases needs the diagnostic procedure

which is lung biopsy. However, there is this problem in its feasibility. Not all people with

the lung disease can have lung biopsy and this leads to the misdiagnosis of the patients

having the condition and receive the wrong treatment and medication. Corticosteroids

were the alternatives in treating the disease condition but it has been found out, that

corticosteroids are not the solution for all the lung diseases because not all conditions

exhibit inflammation and this drug too causes immunosuppression for patients who use

this medication making them more susceptible in acquiring different infections present in

the environment. With this event, there is this new way of diagnosing the said disease.

This is called the DNA Microarray Chip technology. This distinguishes the gene

2
expression patterns of several types of interstitial lung diseases. With this new

technology, the diagnosis of the different poorly understood lung diseases would be clear

now and through this, right diagnosis and prescribed medication will lead to the wellness

of the individual. The success of the use of this advancement would now provide a basis

for the design of drugs specific to treat the said lung conditions. With this method, it has

been found out that idiopathic pulmonary fibrosis is characterized by the increased

expression of genes involved in the re-growth of lung tissue and has been found out that

it is not an inflammatory condition as it was perceived before.

As members of the health team, nurses play an important role in caring for patients

with this kind of disease. It is a necessity to have skills in accurately assessing the client's

signs and symptoms for a definite diagnosis and appropriate treatments to follow. It is

essential to have a knowledge base of gallbladder disease when providing quality care to

these patients and attend to their needs. People should be open minded because it should

be taken seriously because of the life-threatening effects that may lead to DEATH.

This study will help us know more about the etiologic factors, preventive

measures in order to combat these pathologic conditions. This case study covers the

anatomy and physiology of Pneumonia. It also includes the pathophysiology in relation

with the patient which can give information not only for us nurses but also for those

people who are aware and unaware of their health. This is one way of achieving and

providing the necessary care for our future patients, whether here in the Philippines or

elsewhere around the world.

The researchers decided to choose Pneumonia as their Case Study due to the fact

that this disease has a very high incidence rate both here in the Philippines and in the

3
United States. It is also considered as one of the top five dangerous diseases among

developing countries. The statistics says it all, with this, the group became interested

about the disease. Ergo, as young, vibrant and knowledge seeking student nurses, we

have the responsibility to take advantage of learning in detail such type of disease,

explore its pathologic process, unravel its complications in order for them to provide

pertinent information not only to their fellow student nurses but also to their patients as

well. Also, it is but our duty to provide appropriate Nursing Interventions to be done in

managing the disease for us to provide quality nursing care with TLC and provide health

teachings to the patient on how to prevent further complications for this matter to be

handled well enough.

II. STATISTICS (GLOBAL)

COUNTRY INCIDENCE POPULATION

USA 5,132,154 243,665,405

CANADA 573,668 32,507,874

AUSTRIA 144,260 8,174,762

GERMANY 1,454,551 82,424,609

FRANCE 1,066,309 60,424,213

ITALY 1,074,543 58,057,477

SPAIN 710,837 40,280,780

UK 1,063,600 60,270,708

CHINA 22,920,840 1,298,847,624

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 INDIA 18,795,363 1,065,070,607

INDONESIA 4,207,993 238,452,952

JAPAN 2,247,052 127,333,002

MALAYSIA 415,102 23,522,482

PHILIPPINES 1,521,912 86,241,697

MORTALITY: TEN LEADING (10) LEADING CAUSES

Number and rate/100,000 Populatio
5-Year Average (2000-2004) & 2005 n Philippines
5 Year Average
2005*
Cause (2000-2004)
Number Rate No. Rate
1. Diseases of the Heart 66,412 83.3 77,060 90.4
2. Diseases of the Vascular system 50,886 63.9 54,372 63.8
3. Malignant Neoplasm 38,578 48.4 41,697 48.9
4. Pneumonia 32,989 41.4 36,510 42.8
5. Accidents 33,455 42.0 33,327 39.1
6. Tuberculosis, all forms 27,211 34.2 26,588 31.2
7. Chronic lower respiratory
18,015 22.6 20,951 24.6
diseases
8.Diabetes Mellitus 13,584 17.0 18,441 21.6
9. Certain conditions originating in
14,477 18.2 12,368 14.5
the perinatal period
10. Nephritis, nephrotic syndrome
9.166 11.5 11,056 3.6
and nephrosis
MORBIDITY: TEN LEADING (10) LEADING CAUSES
Number and rate/100,000 Populatio
5-Year Average (2000-2004) & 2005 in Philippines

5 Year
Average (2000- 2005*
CAUSE 2004)
No. Rate No. Rate
1. Acute Lower RTI and Pneumonia 694,209 884.6 690,566 809.9
2. Bronchitis/ Bronchiolitis 669,800 854.7 616,041 722.5
3. Acute Watery Diarrhea 726,211 928.3 603,287 707.6
4. Influenza 459,624 587.0 406,237 476.5
5. Hypertension 314,175 400.5 382,662 448.8
6. TB Respiratory 109,369 139.7 114,360 134.1
7. Diseases of the Heart 43,945 56.2 43,898 51.5
8. Malaria 35,970 46.1 36,090 42.3
9. Chickenpox 79,236 41.1 30,063 35.3
10. Dengue Fever 15,383 19.6 20,107 23.6

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Nurse-Centered Objectives:

As the case study progresses, the group aim to achieve the following objectives:

• To broaden our knowledge and heighten our background about the

disease condition.

• Define the disease condition; its signs and symptoms, understand risk

factors, pathophysiology, and its underlying complications.

• To determine the manifestations and complication that might develop

to prevent from occurrence and know the basic intervention needed for

the disease.

• To provide quality-nursing care by setting specific goals and

appropriate nursing intervention which are essential to the client’s

condition.

• To supplement health teachings to the client especially factors that will

contribute to the continuity of care.

III. NURSING HISTORY

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1. PERSONAL HISTORY

Mr. Sapatero a 58 years old male patient was born on May 24,1958 at

Dolores Mabalacat Hospital? He is a Filipino Catholic citizen currently living at

1318 Carolina St., Villasol, Friendship Angeles City. He was married to his

wife Mrs. Kulotera, and is the head of the family. They have four children;

Mr. Sapatero is an undergraduate of accountancy at HAU, he was not

able to pursue his studies due to financial constraint. According to him, their

monthly expenses are supported by her daughters who are working in Japan.

His wife narrated that her husband’s favorite food are mongo and lamang

loob ng chicken, especially the intestines of chicken. When it comes to their

health, Mr. Sapatero prefers to consult a doctor rather than going to

an”albularyo”, but despite of that they use herbal medications.

2. FAMILY-HEALTH ILLNESS HISTORY

Mr. Sapatero’s father was diagnosed with Tuberculosis, after quite

sometime his mother also experienced symptoms of Tuberculosis and diagnosed

with the same disease. According to MR. Sapatero’s father, his grandmother was

busy cleaning their backyard when suddenly a bicycle accidentally hit her and

she fell over the drainage and she was then sent to the hospital, the doctor then

said that she will bee in the state of comatose. After a month his grandmother

died.

7
3.) HISTORY OF PAST ILLNESS

Mr. Sapatero’s favorite sport was bowling and tennis, when he was

working abroad, he played basketball with his workmates, then his left foot was

sprained because he was accidentally hit by his playmate. He ignored hiw sprain

and took it for granted.

4.) HISTORY OF PRESENT ILLNESS

Mr. Sapatero had a chief complaint of body weakness 1 week prior to

admission and a diagnosis of Gouty Arthitis.

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Legend:

Grandfather Uncle Mother Grandmother Father Client

Deceased
Hypertensive

9
 Based from the above diagram, on the mother side, they don’t have any history of

diseases. On the father side, her Grandfather died because of exposure to chemicals. Four of

her uncles are hypertensive. Baby G is the only person in their family who have this kind of

disease.

3. PERSONAL HISTORY

During Mrs. Y pregnancy with Baby G she has completed her regular once a month

check-up. Even though she is pregnant, she was still doing household chores. She just

stopped doing household chores prior to her delivery. When she was pregnant, she was not

drinking vitamins but instead, she drinks milk and eat fruits and vegetables. She gave birth

on December 11, 2008 at Balitucan District Hospital through NSD, preterm.

Mrs. Y started to experience labor pain by 6:00 am and by 8:15 am she delivered a baby

girl weighing 3.5kgs. She did not experienced pregnancy induced hypertension and other

complications of pregnancy. Bottle feeding was introduced to Baby G upon birth and up to

now.

GROWTH AND DEVELOPMENT

Erik Erickson Psychosocial Stage

Baby G who is currently 8th months old is under Trust vs. Mistrust Stage of Erik

Erickson’s Psychosocial Stage (0-1 y/o). During this stage, it is normal for a child to have

what we call “stranger anxiety”.

According to Mrs. Y, Baby G frowns and cries every time she tries or she attempts to

carry her. Gaining the trust of Baby G was not difficult, but she only wanted her mother or

10
 her father to carry him. It was hard assessing Baby G because he was sometimes irritated and

uncomfortable being touches by others.

Sigmund Freud Psychosexual Stage

Baby G falls under the Oral Stage of Sigmund Freud Psychosexual Stage (0-18 mos.). At

this time, oral activity gives pleasure to the child. The child seeks enjoyment or relief of

tension, as well as for nourishment. The child meets the world orally by crying, tasting and

early vocalizing. And the child uses grasping and touching to explore variations in the

environment. To satisfy this need, Mrs. H provided oral stimulation by wetting the lips using

wet cottons especially when the Baby G was put on NPO.

Jean Piaget Cognitive Development

Baby G falls under the Sensorimotor Stage of Jean Piaget’s Cognitive Development (0-

18mos.). Baby G falls under the substage 3 (4 to 8 mos.). During this time, the child acquired

adaptation and a shifting of attention to objects and the environment. This was proven when

Baby G touches the objects she saw in the crib, she grasped them and did some manipulation.

IMMUNIZATION STATUS

Baby H has a complete immunization status. BCG was given December 18, 2009 when

he was 1 week old. DPT, OPV and Hepatitis B were given on his sixth month, June 2009.

The measles vaccine is scheduled this coming September 11, 2009.

4. HISTORY OF PAST ILLNESS

Baby G frequently experienced cough and colds and fever, usually twice a month. All of

these were treated by using over the counter drugs and some herbal medicines at home.

11
5. HISTORY OF PRESENT ILLNESS

Baby G experienced cough and colds, and on and off fever eight days prior to admission.

Four days prior to confinement she experienced cough and colds with phlegm. All of these

were treated when she was admitted at Balitucan District Hospital. And few hours prior to

confinement she experienced difficulty of breathing and consulted at PMD; chest x-ray was

done revealing pneumothorax, hence transferred to JBLMRH.

6. PHYSICAL EXAMINATION (IPPA-PSA Cephalocaudal Approach)

August 24, 2009 – Admission PE

Skin:
 pinkish
 (-) cyanosis

HEAD
 EENT- anicteric sclera
- pale palpebral conjunctiva

CHEST
 LUNGS- symmetrical chest expansion
- (+) rales and retractions

Lymph nodes:
 (-) lymphadenophaty

Abdomen:
• flat with normal bowel sounds

Rectum:
• (+) patent

August 27, 2009

Received pt. lying in crib, vital signs was taken as follows:
T= 37°C PR=104 bpm RR=96 bpm.

Hair:
♥ hair is thin
♥ black in color
♥ silky and resilient

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♥ no notable presence of infestation

Head and Skull:

♥ head is rounded and symmetric
♥ smooth skull contour, no nodules or masses
♥ no lesions noted

Eyes:
♥ eyebrows and eyelashes are black in color
♥ evenly distributed
♥ eyebrows symmetrically aligned
♥ no discharge
♥ anicteric sclerae
♥ pink palpebral conjunctiva
♥ PERRLA

Ears:
♥ brown in color
♥ symmetrical
♥ auricle aligned with outer canthus of the eye
♥ firm and not tender
♥ no foul smelling discharges

Nose:
♥ symmetric
♥ no discharge
♥ (+) nasal flaring
♥ not tender; no lesions

Mouth:
♥ lips are dry
♥ pink gums; no retraction
♥ tongue is centered
♥ moist, smooth and soft
♥ no tenderness

Heart/Chest:
♥ chest has a normal contour
♥ symmetrical chest expansion
♥ no tenderness and masses
♥ RR= 96

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Lungs:
♥ diminished breath sounds on right lung field

Abdomen:
♥ flat
♥ normal, abdominal bowel sounds
♥ no abnormal findings upon percussion
♥ no masses found upon palpation

Extremities:
♥ fingernails and toenails are of normal curve
♥ no presence of abnormal discoloration
♥ smooth in texture
♥ has a normal capillary refill of less than 2 seconds

Skin:
♥ with fair complexion
♥ no cyanosis
♥ no pallor
♥ no edema and lesions noted
♥ has good skin turgor (skin pinch returns to normal within 1-2 seconds)

August 28, 2009

Received pt. lying in crib, vital signs was taken as follows:
T= 37.8°C PR=96 bpm RR=92 bpm.

Hair:
♥ hair is thin
♥ black in color
♥ silky and resilient
♥ no notable presence of infestation

Head and Skull:

♥ head is rounded and symmetric
♥ smooth skull contour, no nodules or masses
♥ no lesions noted

Eyes:
♥ eyebrows and eyelashes are black in color
♥ evenly distributed
♥ eyebrows symmetrically aligned
♥ no discharge

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♥ anicteric sclerae
♥ pale palpebral conjunctiva
♥ PERRLA

Ears:
♥ brown in color
♥ symmetrical
♥ auricle aligned with outer canthus of the eye
♥ firm and not tender
♥ no foul smelling discharges

Nose:
♥ symmetric
♥ no discharge
♥ (+) nasal flaring
♥ not tender; no lesions

Mouth:
♥ lips are dry
♥ pink gums; no retraction
♥ tongue is centered
♥ moist, smooth and soft
♥ no tenderness

Heart/Chest:
♥ chest has a normal contour
♥ symmetrical chest expansion
♥ no tenderness and masses
♥ RR=92

Lungs:
♥ diminished breath sounds on right lung field

Abdomen:
♥ flat
♥ normal, abdominal bowel sounds
♥ no abnormal findings upon percussion
♥ no masses found upon palpation

Extremities:
♥ fingernails and toenails are of normal curve
♥ no presence of abnormal discoloration
♥ smooth in texture
15
♥ has a normal capillary refill of less than 2 seconds

Skin:
♥ with fair complexion
♥ no cyanosis
♥ no pallor
♥ no edema and lesions noted
♥ has good skin turgor (skin pinch returns to normal within 1-2 seconds)

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7. DIAGNOSTIC AND LABORATORY PROCEDURES

17
 DIAGNOSTIC DATE ORDERED INDICATIONS RESULTS NORMAL ANALYSIS
LABORATORY DATE OR VALUES AND
PROCEDURES RESULT(S) IN PURPOSE ( UNITS USED IN INTERPRETAT
THE HOSPITAL) ION OF
RESULTS
Complete Blood
Count
It measures the total
amount of hemoglobin The result is
Hemoglobin D.O:08-24-09 in the blood, to 114g/l ( 125-175g/l) below normal
D.R:08-24-09 determine the O2 values, which is a
carrying capacity of the symptom of
blood. having an
anemia.

It measures the There was slight

Hematocrit D.O:08-24-09 percentage of RBCS in 0.33 (0.40- 0.52) decrease in the
D.R:08-24-09 the total blood volume. results due to
hemodilution.
It determines the
Leukocytes D.O:08-24-09 number of circulating 7.2 (5-10 x 10g/l) The result is
(WBC) D.R:08-24-09 WBCS of the whole within normal
blood. values.

Phagocytes present in The result is

Neutrophils D.O:08-24-09 the circulation or along 0.75 (0.45-0.65) above normal
D.R:08-24-09 the capillary walls. value indicating
that there is
bacterial or
parasitic
infection.
D.O:08-24-09 Produces antibodies
Lymphocytes D.R:08-24-09 responsible for allergic 0.25 (0.20-0.35) The result is
reactions. within normal
values.
Have phagocytic action
by removing dead and
Monocytes D.O:08-24-09 injured cells, cell 0.04 (0.0 2-0.06) The result is
D.R:08-24-09 fragments and within normal
18
microorganisms. values.
To evaluate platelet
production, to monitor
Platelet Count D.O:08-24-09 and diagnose severe 846 (150-400x10g/l) The result is
19
NURSING RESPONSIBILITIES

Prior:

 Check for the doctor’s order, verify the patient.

 Explain to the patient the purpose of these tests.

 Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.

 Explain to the patient that he may feel slight discomfort from the tourniquet and the needle puncture.

 Tell the patient that no fasting is required.

During:

 Tell the patient when to insert the needle for her to be prepared.

 Encourage the patient to remain calm during the test.

 Assist the patient if necessary/

 Ensure a sterile blood sample from the patient.

 Collect approximately 5 to 7ml of venous blood in the bottle.

 Avoid hemolysis.

After:

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 After completely filling the collection tube, invert it gently several times to thoroughly mix the sample and the anticoagulant.

 Label properly and send the sample to the laboratory immediately.

 Handle the sample gently to prevent hemolysis.

 Apply direct pressure to the venipuncture site, until bleeding stops

 If large hematoma develops at the venipuncture site, monitor pulses distal to the site.

21
 DIAGNOSTIC DATE ORDERED INDICATIONS RESULTS NORMAL ANALYSIS
LABORATORY DATE OR VALUES AND
PROCEDURES RESULT(S) IN PURPOSE ( UNITS USED IN INTERPRETAT
THE HOSPITAL) ION OF
RESULTS
Chest Xray

Chest X-ray Radiographic Report

-it is used in the -The right
Chest X-ray diagnosis of hemidiaphragm No abnormalities of The results
- Commonly Date ordered: pulmonary diseases appears intact. No lungs, pleura, indicate that the
ordered laboratory 08-24-05 and provides definite evidence of thorax, soft tissues, patient has
examination. Date performed: important opening atelectasis vs, mediastinum, heart, possible
08-24-05 information consolidation is seen and aortic arch pneumothorax
concerning the status in the right due to air in the
of heart, costophrenic angle, right hemithorax.
gastrointestinal tract, the rest of the right
thyroid gland, bones hemithorax contains
of the thorax air (possible
pneumothorax)

NURSING RESPONSIBILITIES

Prior:

 Explain the procedure to the patient

22
  Tell the patient that no fasting is required.

 Instruct the patient to remove clothing to the waist and to put on an x-ray gown.

 Inform the pt to remove all metal objects (e.g. neck, faces, pins) so that they do not block visualization of part of the chest

 Tell the patient that he will be asked to take a deep breath and hold it wile the x-ray films are taken.

During:

 After the patient is correctly positioned, tell him to take a deep breath and hold it until the x-ray films are taken by a radiologic

technologist several minutes.

 Inform the patient the no discomfort is associated with chest radiography

After:

 Note that no special care is required following the procedure.

23
 III. ANATOMY AND PHYSIOLOGY

Respiratory System

I. Introduction

Respiratory System, in anatomy and physiology, comprises of organs that deliver

oxygen to the circulatory system for transport to all body cells. Oxygen is essential for

cells, which use this vital substance to liberate the energy needed for cellular activities. In

addition to supplying oxygen, the respiratory system aids in removing of carbon dioxide,

preventing the lethal buildup of this waste product in body tissues. Day-in and day-out,

without the prompt of conscious thought, the respiratory system carries out its life-

sustaining activities. If the respiratory system’s tasks are interrupted for more than a few

minutes, serious, irreversible damage to tissues occurs, followed by the failure of all body

systems, and ultimately, death.

24
 While the intake of oxygen and removal of carbon dioxide are the primary

functions of the respiratory system, it plays other important roles in the body. The

respiratory system helps regulate the balance of acid and base in tissues, a process crucial

for the normal functioning of cells. It protects the body against disease-causing organisms

and toxic substances inhaled with air. The respiratory system also houses the cells that

detect smell, and assists in the production of sounds for speech.

The respiratory and circulatory systems work together to deliver oxygen to cells

and remove carbon dioxide in a two-phase process called respiration. The first phase of

respiration begins with breathing in, or inhalation. Inhalation brings air from outside the

body into the lungs. Oxygen in the air moves from the lungs through blood vessels to the

heart, which pumps the oxygen-rich blood to all parts of the body. Oxygen then moves

from the bloodstream into cells, which completes the first phase of respiration. In the

cells, oxygen is used in a separate energy-producing process called cellular respiration,

which produces carbon dioxide as a byproduct. The second phase of respiration begins

with the movement of carbon dioxide from the cells to the bloodstream. The bloodstream

carries carbon dioxide to the heart, which pumps the carbon dioxide-laden blood to the

lungs. In the lungs, breathing out, or exhalation, removes carbon dioxide from the body,

thus completing the respiration cycle.

II. Structure

The organs of the respiratory system extend from the nose to the lungs and are

divided into the upper and lower respiratory tracts. The upper respiratory tract consists of

the nose and the pharynx, or throat. The lower respiratory tract includes the larynx, or

voice box; the trachea, or windpipe, which splits into two main branches called bronchi;

25
tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike, spongy

organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and

from the lungs. The lungs interact with the circulatory system to deliver oxygen and

remove carbon dioxide.

A. Nasal Passages

Anatomy of the Nose

The uppermost portion of the human respiratory system, the nose is a hollow air

passage that functions in breathing and in the sense of smell. The nasal cavity moistens

and warms incoming air, while small hairs and mucus filter out harmful particles and

microorganisms.

The flow of air from outside of the body to the lungs begins with the nose, which

is divided into the left and right nasal passages. The nasal passages are lined with a

membrane composed primarily of one layer of flat, closely packed cells called epithelial

cells. Each epithelial cell is densely fringed with thousands of microscopic cilia,

26
fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells,

specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial

cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the

mucous membrane, near the surface of the nasal passages. While transporting air to the

pharynx, the nasal passages play two critical roles: they filter the air to remove

potentially disease-causing particles; and they moisten and warm the air to protect the

structures in the respiratory system.

Filtering prevents airborne bacteria, viruses, other potentially disease-causing

substances from entering the lungs, where they may cause infection. Filtering also

eliminates smog and dust particles, which may clog the narrow air passages in the

smallest bronchioles. Coarse hairs found just inside the nostrils of the nose trap airborne

particles as they are inhaled. The particles drop down onto the mucous membrane lining

the nasal passages. The cilia embedded in the mucous membrane wave constantly,

creating a current of mucus that propels the particles out of the nose or downward to the

pharynx. In the pharynx, the mucus is swallowed and passed to the stomach, where the

particles are destroyed by stomach acid. If more particles are in the nasal passages than

the cilia can handle, the particles build up on the mucus and irritate the membrane

beneath it. This irritation triggers a reflex that produces a sneeze to get rid of the polluted

air.

The nasal passages also moisten and warm air to prevent it from damaging the

delicate membranes of the lung. The mucous membranes of the nasal passages release

water vapor, which moistens the air as it passes over the membranes. As air moves over

the extensive capillaries in the nasal passages, it is warmed by the blood in the capillaries.

27
If the nose is blocked or “stuffy” due to a cold or allergies, a person is forced to breath

through the mouth. This can be potentially harmful to the respiratory system membranes,

since the mouth does not filter, warm, or moisten air.

In addition to their role in the respiratory system, the nasal passages house cells

called olfactory receptors, which are involved in the sense of smell. When chemicals

enter the nasal passages, they contact the olfactory receptors. This triggers the receptors

to send a signal to the brain, which creates the perception of smell.

B. Pharynx

Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped

tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the

pharynx is lined with a protective mucous membrane and ciliated cells that remove

impurities from the air. In addition to serving as an air passage, the pharynx houses the

tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any

disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages

and pharynx. The tonsils are strategically located to prevent these organisms from

moving further into the body. One tonsil, called the adenoids, is found high in the rear

wall of the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of the

pharynx on either side of the tongue. Another pair, the lingual tonsils, is found deep in

the pharynx at the base of the tongue. In their battles with disease-causing organisms, the

tonsils sometimes become swollen with infection. When the adenoids are swollen, they

block the flow of air from the nasal passages to the pharynx, and a person must breathe

through the mouth.

28
C. Larynx

Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long

located approximately in the middle of the neck. Several layers of cartilage, a tough and

flexible tissue, comprise most of the larynx. A protrusion in the cartilage called the

Adam’s apple sometimes enlarges in males during puberty, creating a prominent bulge

visible on the neck.

While the primary role of the larynx is to transport air to the trachea, it also serves

other functions. It plays a primary role in producing sound; it prevents food and fluid

from entering the air passage to cause choking; and its mucous membranes and cilia-

bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the

pharynx to be swallowed.

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 Food and fluids from the pharynx usually are prevented from entering the larynx

by the epiglottis, a thin, leaflike tissue. The “stem” of the leaf attaches to the front and top

of the larynx. When a person is breathing, the epiglottis is held in a vertical position, like

an open trap door. When a person swallows, however, a reflex causes the larynx and the

epiglottis to move toward each other, forming a protective seal, and food and fluids are

routed to the esophagus.

If a person is eating or drinking too rapidly, or laughs while swallowing, the

swallowing reflex may not work, and food or fluid can enter the larynx. Food, fluid, or

other substances in the larynx initiate a cough reflex as the body attempts to clear the

larynx of the obstruction. If the cough reflex does not work, a person can choke, a life-

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threatening situation. The Heimlich maneuver is a technique used to clear a blocked

larynx (see First Aid). A surgical procedure called a tracheotomy is used to bypass the

larynx and get air to the trachea in extreme cases of choking.

D. Trachea, Bronchi, and Bronchioles

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6

in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings

of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at

all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the

ends of the “C” are connected by muscle tissue.

The base of the trachea is located a little below where the neck meets the trunk of

the body. Here the trachea branches into two tubes, the left and right bronchi, which

deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch

into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles

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contribute to the cleansing function of the respiratory system, for they, too, are lined with

mucous membranes and ciliated cells that move mucus upward to the pharynx.

E. Alveoli

The bronchioles divide many more times in the lungs to create an impressive tree

with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter.

These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to

the circulatory system and remove carbon dioxide. Interspersed among the alveoli are

numerous macrophages, large white blood cells that patrol the alveoli and remove foreign

substances that have not been filtered out earlier. The macrophages are the last line of

defense of the respiratory system; their presence helps ensure that the alveoli are

protected from infection so that they can carry out their vital role.

Human Lungs

Though the right lung has three lobes, the left lung, with a cleft to accommodate

the heart, has only two. The two branches of the trachea, called bronchi, subdivide within
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 the lobes into smaller and smaller air vessels. They terminate in alveoli, tiny air sacs

surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses into

the blood in the capillaries to be pumped by the heart to the tissues of the body, and

carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.

The alveoli number about 150 million per lung and comprise most of the lung

tissue. Alveoli resemble tiny, collapsed balloons with thin elastic walls that expand as air

flows into them and collapse when the air is exhaled. Alveoli are arranged in grapelike

clusters, and each cluster is surrounded by a dense hairnet of tiny, thin-walled capillaries.

The alveoli and capillaries are arranged in such a way that air in the wall of the alveoli is

only about 0.1 to 0.2 microns from the blood in the capillary. Since the concentration of

oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the

alveoli to the capillaries. The oxygen flows through the capillaries to larger vessels,

which carry the oxygenated blood to the heart, where it is pumped to the rest of the body.

Carbon dioxide that has been dumped into the bloodstream as a waste product

from cells throughout the body flows through the bloodstream to the heart, and then to

the alveolar capillaries. The concentration of carbon dioxide in the capillaries is much

higher than in the alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation

forces the carbon dioxide back through the respiratory passages and then to the outside of

the body.

III. Regulation

The flow of air in and out of the lungs is controlled by the nervous system, which

ensures that humans breathe in a regular pattern and at a regular rate. Breathing is carried

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out day and night by an unconscious process. It begins with a cluster of nerve cells in the

brain stem called the respiratory center. These cells send simultaneous signals to the

diaphragm and rib muscles, the muscles involved in inhalation. The diaphragm is a large,

dome-shaped muscle that lies just under the lungs. When the diaphragm is stimulated by

a nervous impulse, it flattens. The downward movement of the diaphragm expands the

volume of the cavity that contains the lungs, the thoracic cavity. When the rib muscles

are stimulated, they also contract, pulling the rib cage up and out like the handle of a pail.

This movement also expands the thoracic cavity. The increased volume of the thoracic

cavity causes air to rush into the lungs. The nervous stimulation is brief, and when it

ceases, the diaphragm and rib muscles relax and exhalation occurs. Under normal

conditions, the respiratory center emits signals 12 to 20 times a minute, causing a person

to take 12 to 20 breaths a minute. Newborns breathe at a faster rate, about 30 to 50

breaths a minute.

The rhythm set by the respiratory center can be altered by conscious control. The

breathing pattern changes when a person sings or whistles, for example. A person also

can alter the breathing pattern by holding the breath. The cerebral cortex, the part of the

brain involved in thinking, can send signals to the diaphragm and rib muscles that

temporarily override the signals from the respiratory center. The ability to hold one’s

breath has survival value. If a person encounters noxious fumes, for example, it is

possible to avoid inhaling the fumes.

A person cannot hold the breath indefinitely, however. If exhalation does not

occur, carbon dioxide accumulates in the blood, which, in turn, causes the blood to

become more acidic. Increased acidity interferes with the action of enzymes, the

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specialized proteins that participate in virtually all biochemical reaction in the body. To

prevent the blood from becoming too acidic, the blood is monitored by special receptors

called chemoreceptors, located in the brainstem and in the blood vessels of the neck. If

acid builds up in the blood, the chemoreceptors send nervous signals to the respiratory

center, which overrides the signals from the cerebral cortex and causes a person to exhale

and then resume breathing. These exhalations expel the carbon dioxide and bring the

blood acid level back to normal.

A person can exert some degree of control over the amount of air inhaled, with

some limitations. To prevent the lungs from bursting from overinflation, specialized cells

in the lungs called stretch receptors measure the volume of air in the lungs. When the

volume reaches an unsafe threshold, the stretch receptors send signals to the respiratory

center, which shuts down the muscles of inhalation and halts the intake of air.

Diaphragm and Respiration

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As the diaphragm contracts and moves downward, the pectoralis minor and intercostal

muscles pull the rib cage outward. The chest cavity expands, and air rushes into the lungs

through the trachea to fill the resulting vacuum. When the diaphragm relaxes to its

normal, upwardly curving position, the lungs contract, and air is forced out.

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