Applied Bioscience for Health Instability 2

Module: Respiratory System

Key Terms

• Acute bronchitis
• Asthma
• Bronchiolitis
• Chronic bronchitis
• Chronic obstructive pulmonary disease (COPD)
• Croup
• Cyanosis
• Cystic fibrosis
• Diluents
• Dyspnoea
• Emphysema
• Expectorants
• Haemoptysis
• Hypercapnia
• Hypoxaemia
• Hypoxia
• Mucolytic drugs
• Muscarinic antagonists
• Non-small cell lung cancer
• Orthopnoea
• Pertussis
• Pneumonia
• Pulmonary embolism
• Small cell lung cancer
• Status asthmaticus
• Tuberculosis

Summary

Disorders of the pulmonary system

• Obstructive lung disease is characterised by airway obstruction that causes difficult

expiration. Obstructive lung disease can be acute or chronic in nature and includes
asthma, chronic bronchitis and emphysema.
• Asthma is the result of a type 1 hypersensitivity immune response involving the
activity of lymphocytes, IgE, mast cells and eosinophil’s.
• Asthma can be caused by exposure to irritants or allergens.
• Exposure to allergens leads to bronchoconstriction and bronchiole airway oedema.
• In asthma, obstruction is caused by exacerbation episodes of bronchospasm,
bronchial inflammation, bronchiole mucosal oedema and increased mucus
production.
• Asthma staging is based on clinical severity and is used to determine therapy.

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• Asthma is a prevalent and important childhood problem. Its origins are probably
multifactorial, including genetic, allergic and viral-triggered mechanisms. Effective
management is aimed at eliminating known triggers from the environment,
decreasing chronic inflammation in the lungs, and early recognition and treatment of
acute symptoms.
• Acute bronchitis can be caused by bacteria. Typical assessment and investigations
include full patient history, respiratory assessment, sputum MC&S, and if severe
CXR and arterial blood gases (ABG)
• Routine care includes chest physiotherapy, supplemental oxygen as prescribed by
Dr, vital sign observations, respiratory observations monitor all input and output via
fluid balance chart, administer oxygen as prescribed and other general care.
• Chronic bronchitis causes airway obstruction resulting from bronchial smooth muscle
hypertrophy and production of thick, tenacious mucus.
• Chronic obstructive pulmonary disease (COPD) is the coexistence of chronic
bronchitis, emphysema and sometimes asthma.
• COPD is an important cause of hypoxaemic and hypercapnic respiratory failure.
• In emphysema, destruction of the alveolar septa and loss of passive elastic recoil
lead to airway collapse and obstruct gas flow during expiration.
• With emphysema expiration becomes difficult because loss of elastic recoil reduces
the volume of air that can be expired passively and air is trapped in the lungs. Air
trapping causes an increase in expansion of the chest, which puts the muscles of
ventilation at a mechanical disadvantage. This results in increased workload of
breathing.
• COPD is the fourth leading cause of death after cardiovascular disease, cancer and
stroke, and forms a large percentage of all respiratory deaths (45%).
• Approximately 600,000 Australians are affected by COPD.

Infections of the pulmonary system

• Serious lower respiratory tract infections occur most often in the elderly and in
individuals with impaired immunity or underlying disease.
• Viral pneumonia can be severe, but is more often an acute self-limiting lung infection
usually caused by the influenza virus.
• The most common community-acquired pneumonias are caused by bacteria,
particularly those caused by Streptococcus pneumoniae (also known as the
pneumococcus), which has a relatively high mortality rate in the elderly.
• The alveoli and terminal bronchioles fill with infectious debris and exudates and
further damage can lead to fibrin deposition.
• Patients can manifest with fever, chills, productive cough, malaise, pleural pain and
sometimes dyspnoea and haemoptysis (blood in the sputum).
• The white blood cell count is usually elevated, although it may be low if the individual
is debilitated or immunocompromised. Chest X-rays show infiltrates that may involve
a single lobe of the lung or may be more diffuse.
• Tuberculosis is a lung infection caused by Mycobacterium tuberculosis.
• In tuberculosis, the inflammatory response proceeds to isolate colonies of bacterium
by enclosing them in tubercles and surrounding the tubercles with scar tissue. These
may remain dormant within the tubercles for life or, if the immune system breaks
down, cause recurrence of active disease.
• Bronchiolitis is the inflammatory obstruction of bronchiolar small airways. It is most
common in children.

Childhood pulmonary disorders

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• Croup is an acute respiratory illness of young children, usually caused by

parainfluenza virus. This infection causes swelling of the upper trachea. The typical
sign is a seal-like barking cough, which appears after a few days of rhinorrhoea, sore
throat and low-grade fever.
• Cystic fibrosis is an autosomal recessive genetic disease that affects many organ
systems, especially the lungs and digestive system. Airway secretions are
particularly thick and tenacious and the airways develop chronic bacterial infection
with pathogens such as Pseudomonas aeruginosa and Staphylococcus aureus.
Chronic infection, plugged airways and severe inflammation cause long-term lung
damage and ultimately death. However, the prognosis is improving and most patients
with cystic fibrosis now survive to adulthood.

Alterations of pulmonary blood flow and pressure

• Pulmonary vascular diseases are caused by embolism or hypertension in the

pulmonary circulation.
• Pulmonary embolism is occlusion of a portion of the pulmonary vascular bed by a
thrombus (most common), tissue fragment or air bubble. Depending on its size and
location, the embolus can cause hypoxic vasoconstriction, pulmonary oedema,
atelectasis, pulmonary hypertension, shock and even death.

Clinical manifestations of pulmonary alterations

• Hypercapnia is an increased carbon dioxide level in the arterial blood.

• Most causes of hypercapnia are a result of decreased drive to breathe or an
inadequate ability to respond to ventilatory stimulation. Some of these causes
include: (1) depression of the respiratory centre in the brainstem by narcotic drugs
such as morphine and heroin; (2) diseases of the medulla, including infections of the
central nervous system or trauma; (3) thoracic cage abnormalities, as in chest injury;
(4) large airway obstruction, as in tumours or sleep apnoea; and (5) increased work
of breathing or physiological dead space, as in emphysema.
• Hypoxaemia is a reduced oxygen level in the arterial blood caused by (1) decreased
oxygen content of inspired gas, (2) hypoventilation and (3) diffusion abnormality at
the alveolar level.
• Hypoxaemia, or reduced oxygenation of arterial blood (reduced PaO2), is caused by
respiratory alterations.
• Hypoxia, or reduced oxygenation of cells in tissues, may be caused by alterations of
other systems as well e.g. low blood pressure or loss of blood and loss of Hb.
• Hypoxaemia can also be caused by central nervous system disorders or depression
of the respiratory centre in the brainstem by drugs such as morphine and heroin; and
result in a decreased drive to breathe.
• Dyspnoea is described as ‘feeling short of breathe’, increased respiratory effort or
difficulty in breathing. It is a common pulmonary disorder symptom.
• Haemoptysis is expectoration of bloody mucus, which can be caused by bronchitis,
tuberculosis, abscess, cancers (neoplasms) and other conditions that cause
haemorrhage from damaged vessels.
• Cyanosis is a bluish discoloration of the skin caused by desaturation of haemoglobin,
polycythaemia or peripheral vasoconstriction.
• Respiratory tidal volume (TV) or size of breath multiplied by respiratory rate (RR)
equals minute volume (MV). E.g. an average size adult male has a 700ml TV
multiplied by a RR of 18/min = 12,600 mls/min or 12.5 litres/min minute volume.
• Therefore you can assume a MV of 12.5 litres/min is required to maintain normal
cellular metabolism and normal cellular oxygenation for this adult male.

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• A reduced tidal volume results in a decreased minute volume e.g. in the case of an
overdose of narcotic analgesia like morphine. The morphine overdose can cause
reduced consciousness, shallow breathing/reduced size of breath (reduced
respiratory tidal volume) and reduced respiratory rate e.g. 350ml TV multiplied by a
RR of 12/min = 4,200 ml/min or 4.2 litres/min. This is a significant decrease from the
normal MV of 12.5 litres/min. Therefore normal cellular oxygenation and cellular
metabolism cannot be maintained.
• Be mindful that any patient that presents with reduced respiratory rate (bradypnoea)
may also have shallow breathing (reduced TV) and therefore reduced minute
volume.
• A decreased minute volume can result in reduced oxygen/carbon dioxide gas
exchange at the alveoli level, reduced oxygen saturations and cellular hypoxia.

Pharmacotherapy

• Oxygen is a therapeutic gas that is essential to sustaining life and is used in many
clinical situations, especially to treat hypoxia.
• Patients may demonstrate low oxygen saturations or hypoxia and supplemental
oxygen therapy may be prescribed by the Dr e.g. oxygen via nasal prongs, Hudson
mask or non-rebreather mask.
• Patients with abnormal or excessive respiratory tract secretions often need
mucoactive drugs. These promote the removal of respiratory tract secretions by
thinning hyperviscous secretions, thus enhancing the ciliary action of the respiratory
tract.
• Mucolytics such as acetylcysteine may break down and reduce the viscosity of
sputum.
• Expectorants aid in the removal of sputum.
• Asthma is a major cause of morbidity and mortality in the community. Treating
asthma involves educating the patient; regular monitoring of lung function, progress
and compliance; avoiding trigger factors; and stepwise use of various antiasthma
drugs.
• The main drug groups used in asthma are:
o reliever (bronchodilator) medications (short-acting β2 agonists, xanthine’s and
antimuscarinic agents) e.g. ventolin
o symptom controllers (long-acting β2 agonists) e.g. salmeterol
o preventer medications (inhaled corticosteroids, leukotriene-receptor
antagonists and mast-cell stabilisers). E.g. pulmicort
• Cough suppressants such as the opioid antitussive drugs are used for non-
productive coughs.
• Viral respiratory tract infections (cold, influenza, croup) are treated largely
symptomatically.
• Bacterial respiratory tract infections (pneumonia, tuberculosis, and infections in
COPD) are treated with antibiotics specific to the pathogenic organism.

Glossary
• Acute bronchitis: is an acute infection or inflammation of the airways or bronchi and
is usually self-limiting.
• Asthma: obstruction is caused by exacerbation episodes of bronchial inflammation,
bronchiole mucosal oedema, bronchospasm and increased mucus production.
• Bronchiolitis: is a rather common, viral-induced lower respiratory tract (bronchiolar)
infection that occurs almost exclusively in infants and young toddlers.
• Chronic bronchitis: is a chronic infection or inflammation of the airways or bronchi

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• Chronic obstructive pulmonary disease (COPD): is a syndrome that includes the

pathological lung changes consistent with emphysema, chronic bronchitis or chronic
asthma.
• Croup: is an acute inflammation of the upper airways and almost always occurs in
children between 6 months and 5 years of age. In 85% of cases, croup is caused by
a virus. Airway obstruction occurs in the subglottic region of the trachea, just below
the vocal cords.
• Cyanosis: is a bluish discoloration of the skin and mucous membranes caused by
increasing amounts of desaturated or reduced haemoglobin (which is bluish) in the
blood
• Cystic fibrosis: is an autosomal recessive inherited disease that results from
defective epithelial chloride ion transport. Although cystic fibrosis affects many
organs the most important effects are on the lungs and in 90% of cases, chronic
pulmonary infections eventually lead to respiratory failure and death.
• Diluents: The agent most commonly used to dilute respiratory secretions is normal
saline, administered by ultrasonic nebulizer.
• Dyspnoea: is the subjective sensation of uncomfortable breathing, the feeling of not
being able to get enough air. Sometimes referred to as difficulty in breathing.
• Emphysema: is abnormal permanent enlargement of gas-exchange airways
accompanied by destruction of alveolar walls. Obstruction results from changes in
lung tissue.
• Expectorants: act by an irritant action on the mucous membranes, which increases
the secretion of mucus from bronchial secretory cells, facilitating ciliary action and
productive coughing and soothing and lubricating dry tissues.
• Haemoptysis: is the coughing up of blood or bloody secretions.
• Hypercapnia: increased carbon dioxide in the arterial blood (increased PaO2).
• Hypoxaemia: reduced oxygenation of arterial blood (reduced PaO2)
• Hypoxia: reduced oxygenation of cells in tissues e.g. oxygen saturations below 90%.
• Mucolytic drugs: exert a disintegrating effect on mucus, facilitating removal of
mucus or other exudates from the lung, bronchi or trachea by postural drainage,
coughing, spitting or swallowing e.g. acetylcystine
• Muscarinic antagonists: one of the many pharmacological effects of muscarinic-
receptor antagonists (antimuscarinic drugs) such as atropine is inhibition of bronchial
secretions. Dries secretions. E.g. ipratropium
• Non-small cell lung cancer: Squamous cell carcinoma accounts for about 30% of
bronchogenic carcinomas. These tumors are typically located near the hilum and
project into the bronchi. Adenocarcinoma (meaning that the tumor arises from the
glands) constitutes 35–40% of all bronchogenic carcinomas.
• Orthopnoea: dyspnea when a patient is lying down.
• Pertussis: is caused by the bacterium Bordetella pertussis. The symptoms are thick
secretions, a chronic cough and spasm following coughing fits, which give a
characteristic ‘whoop’ sound — hence the common name ‘whooping cough’
• Pneumonia: is infection of the lower respiratory tract caused by bacteria, viruses,
fungi, protozoa or parasites. The alveoli and terminal bronchioles fill with infectious
debris and exudate.
• Pulmonary embolism: is occlusion of a portion of the pulmonary vascular bed by
an embolus, which can be a thrombus (blood clot), tissue fragment, lipids (fats),
foreign body or an air bubble (air embolism). More than 90% of pulmonary emboli
result from clots formed in the veins of the legs and pelvis.
• Small cell lung cancer: Small cell carcinomas constitute 15–20% of bronchogenic
carcinomas. Most of these tumors are central in origin
• Status asthmaticus: defined as a severe asthmatic episode that does not respond
to pharmacological management.
• Tuberculosis: is an infection caused by Mycobacterium tuberculosis, a bacterium
that usually affects the lungs but may invade other body systems. Inflammation in the
lung causes activation of alveolar macrophages and neutrophils.

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Medications
Key Drugs: Learning activity > list some common side effects in the tables below.
Go to MIMS online (right click hyperlink and open)

Pharmaceutical Salbutamol Terbutaline Salmeterol

name
Brand name Ventolin Bricanyl Turbuhaler Serevent
Indications for use Relief of Relief of Adjunct to steroids
bronchospasm bronchospasm in in asthma (incl
(asthma, COPD); asthma, COPD nocturnal, exercise
acute asthma induced)
prophylaxis (incl
exercise induced
asthma);
Drug class Bronchodilator Bronchodilator Bronchodilator
aerosols and aerosols and aerosols and
inhalations inhalations inhalations
Pharmacological Short acting beta 2 Beta 2 -agonist Selective long
action/mechanism -adrenoreceptor acting beta 2 -
of action stimulant agonist
Physiological effect Bronchial smooth sympathomimetic sympathomimetic
muscle dilation bronchodilator bronchodilator
Route of Inhaled Inhaled Inhaled
administration
Common side Tachycardia, Tremor and Thrush of
effects hypotension, headache mouth/throat,
headache tremor, headache,
tachycardia

Pharmaceutical Budesonide
name
Brand name Pulmicort
Turbuhaler
Indications for use Bronchial asthma;
Drug class Preventive
aerosols and
inhalations
Pharmacological Glucocorticoid.
action/mechanism
of action
Physiological effect Anti-inflammatory
Route of Inhaled
administration
Common side Sore throat, oral
effects thrush

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References

Bryant, B. & Knights, K. (2011) Pharmacology for Health Professionals (3rd ed).
Elsevier Mosby.
Craft, J., Gordon, C., Huether, S., McCance, K., & Brashers, V. (2020). Understanding
Pathophysiology (4th ed.). Elsevier Mosby.

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