I.

INTRODUCTION

A. Current trends about the disease condition

Pneumonia is an illness of the lungs and respiratory system in which the alveoli

(microscopic air-filled sacs of the lung responsible for absorbing oxygen from the

atmosphere) become inflamed and flooded with fluid. Pneumonia can result from a variety

of causes, including infection with bacteria, viruses, fungi, or parasites.

It is also called Pneumonitis or Bronchopneumonia. Although Pneumonitis is actually

a general term which refers to the inflammation of the lungs and Pneumonia is one of the

common Pneumonitis. While it is called Bronchopneumonia because “broncho” indicate that

of the lungs. Pneumonia is a serious infection that affects the air sacs in the lungs, resulting

to significant reduction in oxygenation. Because of this, the oxygen will have difficulty

reaching the blood. If there is too little oxygen in the blood, body cells cannot work

properly. As a result, infection will spread.

Pneumonia is a special concern to both extremes of age – the too old and the too

young, because it is during this time the individual is most at risk, for the too old, it is for the

reason that their immune system is degenerating, while for the too young it is because their

immune system is not yet fully developed. Although these extremes of age are greatly at

1
risk, Pneumonia can also affect healthy individuals, it is a common illness that affects

thousands of people in the Philippines each year. It remains as the leading cause of

morbidity in the country (according to the Department of Health).

Appropriate nursing care should be given to patients with Pneumonia. Health care

providers should remain vigilant with regards to dealing with this kind of disease. Nurses, in

cooperation with other members of the health care team should not only focus on the

curative aspect of the disease but to its preventive aspect as well. A patient with pneumonia

should be given appropriate care in order to hasten his/her recovery. The focus should not

only be in the patient himself but to the public as well for a person with pneumonia could

also infect other people around him/her.

A major trial of a pneumococcal vaccine in South Africa has given children extra

protection against the deadly infection.

The World Health Organization (WHO), which helped run the testing program, says

that pneumonia, caused by pneumococcus bacteria, is the leading cause of death in children

worldwide. It claims approximately four million lives a year, predominantly in less

developed countries.

Although the lung congestion has many causes, the most common is pneumococcus.

The bacterium can also cause meningitis, ear infections and sinusitis.

The trial involved 40,000 children in Soweto, and found that the new vaccine

reduced the incidence of pneumonia by more than 20%.

2
 In addition, the vaccine reduced the incidence of "invasive pneumococcal disease" -

where bacteria can be found in the bloodstream - by more than 80%. The invasive form of

the disease was reduced in incidence even in HIV-infected children.

Pneumococcal disease is one of the predatory illnesses most likely to kill HIV-

positive children in developing countries.

Researchers show a new type of vaccine can reduce the incidence of pneumonia in

children with and without human immunodeficiency virus (HIV). Acute respiratory

infections are a major cause of death in children under age 5. Additionally, pneumonia is

becoming increasingly resistant to antibiotics. Doctors from around the world are in search

of new methods to treat the illness. Researchers, conducted a study with nearly 40,000

children in South Africa. At 6 weeks, 10 weeks and 14 weeks of age, half of the children

received the 9-valent pneumococcal polysaccharide vaccine. All of the children received the

flu vaccine. The researchers found the pneumonia vaccine decreased the rate of the

particular strain of pneumonia in the vaccine, by 72 percent. It also reduced the rate of

confirmed cases by 17 percent. In an accompanying editorial, the authors write, “The

decrease in these two outcomes were remarkably similar in both U.S. children and South

African children. However, in South Africa about one third of the cases of invasive disease

caused by serotypes included in the vaccine were associated with meningitis, a much higher

proportion than in the United States.” This vaccine, according to the study investigators,

may be useful in countries where HIV infection is a significant cause of pneumonia. It also

may reduce the risk of antibiotic resistance. However researchers noted an increase in

asthma in those who received the vaccine, but that reason is not yet understood.

3
 Another study showed particularly UT Southwestern Medical Center scientists have

revealed that a combination of corticosteroids with traditional antimicrobial therapy may

help people with pneumonia recover more quickly than with antibiotics alone.

Corticosteroids are often used to treat inflammation related to infectious diseases, such as

bacterial meningitis, but they have been rendered ineffective in case of other infectious

diseases. In a new study, scientists have shown that mice with a type of severe bacterial

pneumonia, when treated with steroids and antibiotics recovered faster. The steroid treated

mice had far less inflammation in their lungs than mice treated with antibiotics alone. "Some

people might think that if you give steroids, it would counteract the effect of the antibiotic.

But it turns out you need the antibiotic to kill the bug and the steroid to make the

inflammation in the lung from the infection get better. The steroids don't kill the bugs, but

they do help restore health," said Dr. Robert Hardy, associate professor of internal medicine

and pediatrics and the study's senior author. For the study, the researchers gave a daily

treatment of a placebo, an antibiotic, a steroid, or a combination of the antibiotic and steroid

to mice infected with the M pneumoniae bacterium. The animals were then evaluated after

one, three and six days of therapy. "It turns out that the group that got both the antibiotic and

the steroids did the best. The inflammation in their lungs got significantly better," said

Hardy

. While antimicrobials have been the primary therapy for M pneumoniae infection, many

physicians have tried adding steroids to the treatment regimen of patients with severe cases.

But, Hardy said that the problem is that those were individual case reports. "They never had

a control group, so it was impossible to tell what impact the addition of steroids had on

recovery," he said. The new findings suggest that giving antibiotics with steroids can help

4
individuals with pneumonia get better faster. Also, the research suggests a potentially more

effective therapy for someone in the midst of an asthma attack due to M pneumoniae

infection.

The student nurses chose Pneumonia for a case study because it is a very interesting

topic. It is one of the common problems in the country. It remains the leading cause of

morbidity in the Philippines as stated by the department of Health. It is commonly mistaken

as a common cough and cold because it manifests almost the same signs and symptoms, for

this reason, people with this respiratory problem usually take it for granted. With this, the

student-nurses decided to choose the case of Pneumonia for their case study.

OBJECTIVES

A. Student-Nurse Centered

After the completion of the case study, the researchers will be able to:

General Objective:

Gain knowledge and deeper understanding of the disease process itself, be able to

provide the best nursing care for the client, and impart health teachings regarding the client’s

condition in maintaining an optimum level of functioning.

Specific Objectives:

1. Interpret the current trends and statistics regarding the disease condition;

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 2. Relate the present state of the client with his personal and pertinent family history;

3. Analyze and interpret the different diagnostic and laboratory procedures, its purpose

and its essential relationship to client’s disease condition;

4. Identify treatment modalities and its importance like drugs, diet and exercise;

5. Identify surgical management and its purpose that is applicable with the disease

condition;

6. Formulate nursing care plans based on the prioritized health needs of the client;

7. Gain knowledge on the acquisition and progression of the disease;

8. Impart knowledge on fellow students in providing care for clients with the same

illness.

B. Patient-Centered

After the completion of the study, the patient will be able to:

General Objective:

Acquire knowledge on the risk factors that have contributed to the development of

the disease, gain understanding of the disease process and demonstrate compliance on the

treatment management rendered by the health care team.

Specific Objectives:

1. Gain knowledge about the disease;

2. Identify different interventions in his condition;

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 3. Gain knowledge on the importance of compliance to treatment regimen;

4. Demonstrate compliance on the treatment management;

5. Identify different measures to prevent further aggravation of condition;

6. Participate in his plan of care; and

7. Demonstrate independence on self-care and home management upon discharge and

during follow-up home visits.

II. GENERAL DATA

Name : Francisca Daan Atillo

Address : Basak Pardo, Cebu City

Gender : Female

Age : 93 years old

Date of Birth : July 16, 1917

Place of Birth : Basak Pardo, Cebu City

Religion : Roman Catholic

Nationality : Filipino

Civil Status : Married

Educational attainment: College Graduate

Admission Data:

Chief Complaint : Body weakness associated with Fever & Cough for 4 days

Date of Admission : July 21, 2010

7
Time of Admission : 08:50 pm

Clinical Diagnosis : Pneumonia

Attending Physician : Dr. Escarda

III. HEALTH ASSESSMENT

A. HEALTH HISTORY

A.1 BIOLOGICAL DATA

PERSONAL and SOCIAL HISTORY

FDA is a non smoker and a non alcoholic. She described herself as simple and

approachable. She might have a slow voice but she said she is talkative when someone used

to talk to her. During her high school and college years, she loved to be with her friends and

boyfriend. She may look strict but deep inside she is friendly especially if she first gets a

smile from anyone. She works hard especially when she became a mother and a wife. She is

a retard teacher and a loving mother. She and her husband works very hard just to let their

children finished their courses. She has a daughter who works now in California as a nurse

and her two sons are now in texas as a seaman and a nurse. Her husband died at the age of

72, due to a cardiovascular attack. After then, she focuses more on their businesses. She

usually spends her free time watching television and listening to radio. She spent her vacant

time sleeping to relax herself. She eats three times a day excluding snacks. She usually

8
sleeps between 9pm-10pm. Her rising time was at 5 am. Whenever she had a problem, she

will ask for help to her sisters and husband. But now, she will come to her daughter. She

does simple exercise every morning like walking to their garden and does household chores.

She is very religious and attends masses every Sunday, sometimes every day.

ENVIRONMENTAL HISTORY

FDA and her family owned a house at Basak Pardo, Cebu City. They live in that

place for almost 52 years. On their house, she said that they are fine and comfortable with

the place since they live there for such a long time. The space of their house is just enough

for them. But now, since she and her one daughter left there, it was big for them. They have

their own comfort room, water and electrical supply. Their neighbors are good and so

approachable. They maintain cleanliness of their environment by having proper disposal of

waste and drainage system.

A.2 REASON FOR SEEKING CONSULTATION

Patient seek for consultation prior to her fever and unproductive cough for 4 days

and due to body weakness.

A.3 CURRENT HEALTH STATUS

Mrs. FDA, 93 years old, widowed from Basak Pardo, Cebu City was a patient at

9
VCMC. He was confined last July 21, 2010 because of body weakness, unproductive cough

and high grade fever 4 days before confinement.

When he was confined in the hospital, Mrs. FDA said that he experienced body malaise and

chills whenever he has a high grade fever. His daughter said that it was her first time that he

saw her father experienced high grade, fever of 39.4 during our duty hours of 7-3 pm.

A.4 PAST HEALTH HISTORY

On her early childhood, she had chicken pox and measles. Every time she had a fever

she will take paracetamol. She sometimes had a diarrhea and headache but she will just take

a medicine for it. At the age of 36 she had a cough which takes more than 1 week and her

daughter brought her to the hospital for a checkup and was advised to be admitted. She had a

diagnosis of dengue fever due to a very high fever. She remembers that she was so tired at

that time that she can’t even walk for a while. She received a complete immunization. She

was not able to undergone any operation and was never experienced to be injured. She does

not have any food and drugs allergies.

A.5 FAMILY HISTORY

Patient states that in his father’s side there is no genetic factor or illness inherited. In

contrary, hypertension is in the bloodline of his mother’s side. Patient belongs to a nuclear

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 type of family. They were 6, two girls and two boys including her mother and father. She is

the third daughter.

(see appendix A for Genogram)

A.6 REVIEW OF SYSTEMS

Area Assessed Technique Normal Findings Actual Findings Evaluation

Skin Inspection Light brown, Light brown skin Normal

Color tanned skin (vary
according to race

Soles and palms Inspection Lighter colored Lighter colored Normal

palms, soles palms, soles

Moisture Inspection/ Skin normally dry Skin normally dry Normal

palpation

Temperature palpation Normally warm Slightly hot due to infection

Normal

Texture Palpation Smooth and soft Smooth and soft Normal

Turgor Palpation Skin snaps back Skin snaps back Normal

immediately immediately

Skin Inspection Transparent, Transparent, Normal

appendages smooth and convex smooth and convex

a. Nails

Nail beds Inspection Pinkish Pale Due to

decreased
blood flow

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Nail base Inspection Firm Firm Normal

Capillary refill Inspection/ White color of nail Returns within 2-3 Normal
Palpation bed under pressure seconds
should return to Normal
pink within 2-3
seconds

b. Hair Inspection Evenly Evenly distributed Normal

Distribution distributed
Color Inspection Black Black Normal

Texture Inspection/ Smooth Smooth Normal

Palpation

Eyes Inspection Parallel to each Parallel to each Normal

Eyes other other

Visual Acuity Inspection PERRLA- Pupils PERRLA- Pupils Normal

(penlight) equally round react equally round react
to light and to light and
accommodation accommodation

Eyebrows Inspection Symmetrical in Symmetrical in Normal

size, extension, size, extension,
hair hair
texture and texture and
movement movement
Eyelashes Inspection Distributed evenly Distributed evenly Normal
and curved and curved
outward outward

Eyelids Inspection Same color as the Same color as the Normal

skin skin
Blinks Blinks
involuntarily and involuntarily and
bilaterally up to 20 bilaterally up to 20
times per minute times per minute
Do not cover the Do not cover the
pupil and the pupil and the
sclera, lids sclera,
normally close lids normally close
symmetrically

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 symmetrically
Transparent with
light pink color
Transparent with
light pink color
Conjunctiva Inspection Normal

Sclera Inspection Color is white Color is white Normal

Cornea Inspection Transparent, shiny Transparent, shiny Normal

Pupils Inspection Black, constrict Black, constrict Normal

briskly briskly

Iris Inspection Clearly visible Clearly visible Normal

Ears Inspection Free of lesions, Free of lesions, Normal

Ear canal discharge of discharge of
opening inflammation inflammation

Canal walls pink Canal walls pink Normal

Nose Inspection Smooth, symmetric Smooth, Normal

Shape, size and with same color as symmetric
skin color the face with same color as
the face

Nares Inspection Oval, symmetric Oval, symmetric Normal

Oval, symmetric and without and without
and without discharge discharge
discharge
Norma

Mouth and Inspection Pink, moist Light pink, dry, Lack of fluid
Pharynx symmetric symmetric intake
Lips

Buccal mucosa Inspection Glistening pink Glistening pink Normal

soft soft
moist moist

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Gums Inspection Slightly pink color, Slightly pink color, Normal
moist and tightly moist and tightly
fit fit
against each tooth against each tooth

Tongue Inspection Moist, slightly Moist, slightly Normal

Moist, slightly rough on dorsal rough on dorsal
rough on dorsal surface medium or surface medium or
surface medium or dull red dull red
dull red
Norma

Teeth Inspection Firmly set, shiny Firmly set, shiny Normal

Hard and soft Inspection Hard palate- dome- Hard palate- dome- Normal
palate shaped shaped
Soft Palate- light Soft Palate- light
pink pink

Neck Inspection Neck is slightly Neck is slightly Normal

Symmetry of hyper extended, hyper extended,
neck muscles, without masses or without masses or
alignment of asymmetry asymmetry
trachea

Neck ROM Inspection Neck moves freely, Neck moves freely, Normal
without discomfort without discomfort
Thyroid gland Palpation Rises freely with Rises freely with Normal
swallowing swallowing

Thorax and Auscultation Clear breath Clear breath Normal

Lungs sounds sounds

Abdomen Inspection Skin same color Skin same color Normal

with the rest of the with the rest of the
body body

Clicks or gurling Clicks or gurling

sounds occur sounds occur
Bowel sounds Auscultation irregularly and irregularly and Normal
range from 5-35 range from 20 per
per minute

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 minute
Extremities
Symmetrical
Symmetry Inspection Symmetrical Normal
Same with the
color of other parts
of the body
Skin color Inspection Same with the Normal
Evenly distributed color of other parts
of the body
Warm to touch

No lesions
unevenly
Hair distribution Inspection Moves freely distributed Normal
without discomfort

Skin Warm to touch

Temperature Palpation Normal

Presence of No lesions
lesion Inspection Normal

Able to move but

ROM Inspection with assistance Due to body
weakness

Neurology Inspection Fully conscious, Fully conscious, Normal

system respond to respond to
Level of questions quickly, questions quickly,
consciousness perceptive of perceptive of
events events
Behavior and Inspection Makes eye contact Makes eye contact Normal
appearance with examiner, with examiner,
hyperactive hyperactive
expresses feelings expresses feelings
with response to with response to
the the
situation situation

A.7 Psychosocial Profile

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 GORDONS 11 FUNCTIONAL HEALTH PATTERN

FUNCTION BEFORE DURING INTERPRETATIO

HOSPITALIZATION HOSPITALIZATION N
Nutrition - Eat 3x a day - mostly eat bread - doctors order DAT
- she love to eat bread diet to the patient and
and processed food such NCCF.
as hotdog, tocino,
longanisa and others.
- she loves to eat
vegetables and fish
- seldom drink water
- this time she frequently - to replace fluid loss
drink water
Elimination - she is able to urinate - she can still urinate and - her condition does
and defecate normally defecate with an affected her
everyday by himself. assistance. elimination pattern.
- she doesn’t have any
problem on his
elimination
- defecates usually in the
morning.

Sleeping - she has regular sleeping - disturbed sleeping - due to adherence to

pattern pattern. time of medication &
- normally sleep 6-8 vital signs
hours per day. monitoring.

Cognitive- Perceptual- - has normal cognitive - she is responsive and - portraying

Pattern perception can communicate well. cooperativeness
- can comprehend well
- she responds
appropriately to verbal
and physical stimuli.
Self- Perception-Self -perceived herself as a - this time she perceived - due to her ability to
concept good friend, mother. herself as an establish good rapport
approachable person to other people.

16
Role Relationship - she was able to do his - this time her role as a - due to her condition
Pattern responsibility as a mother patient is not fully met she is not aware of
performing his real
role in this field.

Sexuality- - she does think of the of - same -due to her ageful

Reproductive Patten being married mind, it is still not her
priority in life.
Coping stress & - she doesn't fully - same - at her age she still
Tolerance Pattern identifies her stressors. can do household
chores & she doesn't
mind the stressors in
mind.
Activity- Exercise - her daily routine was - she interacts with other - she only focuses on
Pattern helping her helper to do people around her the simple things.
household chores. -cooperates well to the
- Her daily activities doctor & nurses
were limited in waking
up in the morning to
attend masses.
Value- belief Patten - she is a catholic. - due to their culture
preferences & parents
influence.
Health perception- - she perceived her health - she thinks that she is - due to his illness.
health Management in the state of good not healthy.
Patten health.

B. PHYSICAL EXAMINATION

July 21, 2010(Day of admission)

Patient FDA upon admission: (lifted from the chart)

• Flushed skin

• (-) Edema

17
 • Vital Signs:

o Body temperature of 39.4 OC (afebrile) (Normal=36.8OC)

o Heart rate of 135 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 46 bpm (tachypnea) (Normal=25-40bpm)

July 26, 2010(1st contact)

• General appearance:

o conscious and coherent

o irritable

• Vital Signs: (lifted from the chart)

o Body temperature of 37.9 OC (febrile) (Normal=36.8OC)

o Heart rate of 130 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 48 bpm (tachypnea) (Normal=25-40bpm)

July 27, 2010(2nd contact)

• General appearance:

o conscious and coherent

o irritable

• Vital Signs:

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 o Body temperature of 37.6 OC (febrile) (Normal=36.8OC)

o Heart rate of 130 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 46 bpm (tachypnea) (Normal=25-40bpm

• Head:

o No tenderness upon palpation

o No presence of lesions and scar

o symmetric facial features and movement

• Skin:

o Fair complexion

o With good skin turgor

o (-) cyanosis

o No lesions or rashes noted

o Flushed skin

o Pale skin

• Hair:

o Hair is not evenly distributed

o Has short, white and dry hair

o No presence of dandruff and pediculosis upon inspection

• Nails:

o Nails are clean and short

o Capillary refill 2-3 sec.

• Eyes and Vision:

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 o Both eyes are symmetrical

o Elicited blink reflex upon assessment

o Has pale conjunctiva

o Dark circles under the eyes

o Sclera appears white

o Pupils are equally round reactive to light and accommodation

• Ears:

o Ears are at the level of the outer cantus of the eye

o They are symmetrical in size and shape

o No presence of lesions noted

o No presence of discharges

o Pinna recoils after it is folded

• Nose and sinuses:

o Presence of clear, watery discharges

o No lesions noted

o No presence of tenderness upon palpation

o With nasal flaring noted

• Mouth:

o No lesions and tenderness noted

o Teeth are white and clean

o No presence of dental caries

• Neck:

20
 o Absence of masses

o No pain and swelling

o Trachea is on the middle of the neck

• Thorax and Lungs:

o With symmetrical lung expansion

o Presence of wheezes on bilateral lung fields

o Respiratory rate is above normal (46bpm)

o Difficulty of breathing and shortness of breath

• Abdomen:

o No tenderness upon palpation

o Absence of wounds, scar, and lesion upon inspection

o Absence of swelling or lump upon palpation

• Extremities:

o No scar, lesion and wounds noted

o No deformities

o Absence of nodule and edema

o Symmetrical in shape and size

July 30, 2010 (last contact)

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• General appearance:

o conscious and coherent

o irritable

• Vital Signs:

o Body temperature of 36.7OC (febrile) (Normal=36.8OC)

o Heart rate of 121 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 35 bpm (tachypnea) (Normal=25-40bpm

• Head:

o No tenderness upon palpation

o No presence of lesions and scar

o symmetric facial features and movement

• Skin:

o Fair complexion

o With good skin turgor

o (-) cyanosis

o No lesions or rashes noted

o Flushed skin

o Pale skin

• Hair:

o Hair is not evenly distributed

o Has short, white and dry hair

22
 o No presence of dandruff and pediculosis upon inspection

• Nails:

o Nails are clean and short

o Capillary refill 2-3 sec.

• Eyes and Vision:

o Both eyes are symmetrical

o Elicited blink reflex upon assessment

o Has pale conjunctiva

o Dark circles under the eyes

o Sclera appears white

o Pupils are equally round reactive to light and accommodation

• Ears:

o Ears are at the level of the outer cantus of the eye

o They are symmetrical in size and shape

o No presence of lesions noted

o No presence of discharges

o Pinna recoils after it is folded

• Nose and sinuses:

o Presence of clear, watery discharges

o No lesions noted

o No presence of tenderness upon palpation

o With nasal flaring noted

23
• Mouth:

o No lesions and tenderness noted

o Teeth are white and clean

o No presence of dental caries

• Neck:

o Absence of masses

o No pain and swelling

o Trachea is on the middle of the neck

• Thorax and Lungs:

o With symmetrical lung expansion

o Presence of wheezes on bilateral lung fields

• Abdomen:

o No tenderness upon palpation

o Absence of wounds, scar, and lesion upon inspection

o Absence of swelling or lump upon palpation

• Extremities:

o No scar, lesion and wounds noted

o No deformities

o Absence of nodule and edema

o Symmetrical in shape and size

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IV. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

Respiratory System, in anatomy and physiology, 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.

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

25
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.

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; 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.

26
 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, 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

27
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. If the

nose is blocked or “stuffy” due to a cold or allergies, a person is forced to breathe 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.

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

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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.

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-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.

TRACHEA, BRONCHI, 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 contribute to the

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cleansing function of the respiratory system, for they, too, are lined with mucous membranes

and ciliated cells that move mucus upward to the pharynx.

Human Lungs

In humans the lungs occupy a large portion of the chest cavity from the collarbone

down to the diaphragm. The right lung is divided into three sections, or lobes. The left lung,

with a cleft to accommodate the heart, has only two lobes. The two branches of the trachea,

called bronchi, subdivide within the lobes into smaller and smaller air vessels known as

bronchioles. Bronchioles 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. At the same time carbon dioxide diffuses out

of the blood into the lungs, where it is exhaled.

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

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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.

Alveoli

A scanning electron micrograph reveals the tiny sacs known as alveoli within a

section of human lung tissue. Human beings have a thin layer of about 700 million alveoli

within their lungs. This layer is crucial in the process called respiration, exchanging oxygen

and carbon dioxide with the surrounding blood capillaries.

CNRI/Photo Researchers, Inc.

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.

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 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.

Diaphragm and Respiration

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

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

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

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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 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

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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.

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