Chapter IV

A. REVIEW

OF

ANATOMY

AND

PHYSIOLOGY

OF

RESPIRATORY SYSTEM

The purposes of breathing are (1) to provide oxygen for tissue

perfusion so that cells have enough oxygen to metabolize and
generate energy and (2) to remove carbon dioxide, the waste product
of metabolism. The respiratory system also influences acid-base
balance, speech, sense of smell, fluid balance, and temperature
control. The lungs are also an excretory organ because they can also
break down some toxins and eliminate them from the body during
exhalation.
1. Upper Respiratory Tract
The upper airways consist of the nose, the sinuses, the pharynx, and
the larynx
Nose and Sinuses
The nose is the organ of smell, with receptors from cranial nerve
I (olfactory) located in the upper areas. This organ is rigid and contains
two passages separated by the septum. The upper nose is composed
of bone; the lower two thirds is composed of cartilage, allowing some
movement. The septum and interior walls of the nasal cavity are lined
with mucous membranes that have a rich blood supply. The anterior
nares (external openings into the nasal cavities) are lined with skin
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and hair, which help keep particles or organisms from entering the
lungs. The posterior nares are openings from the nasal cavity into the
throat.
The turbinates are three bones that protrude into the nasal cavities
from the internal portion of the nose
Turbinates increase the total surface area for filtering, heating, and
humidifying inspired air before it passes into the nasopharynx. Inspired
air entering the nose is first filtered in the nares. Particles not filtered
out in the nares are trapped in the mucous layer. These particles are
moved by cilia (hairlike projections) to the throat, where they are
either swallowed or expectorated. Inspired air is humidified by the
mucous membrane and is warmed by heat from the vascular network.
The paranasal sinuses are air-filled cavities within the bones that
surround the nasal passages. Lined with ciliated membrane, the
purposes of the sinuses are to provide resonance during speech and to
decrease the weight of the skull.
Pharynx
The pharynx, or throat, is a passageway for both the respiratory
and digestive tracts. It is located behind the oral and nasal cavities.
The throat is divided into the nasopharynx, the oropharynx, and the
laryngopharynx). The nasopharynx is located behind the nose, above
the soft palate. It contains the adenoids and the opening of the
eustachian tube. The adenoids trap organisms that enter the nose or
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mouth. The eustachian tubes connect the nasopharynx with the

middle ears and open during swallowing to equalize pressure within
the middle ear. The oropharynx is located behind the mouth, below the
nasopharynx. It extends from the soft palate to the base of the tongue
and is used for breathing and swallowing. The palatine tonsils, which
are part of the immune system, are located on the side borders of the
oropharynx. They guard the body against invading organisms. The
laryngopharynx is the area located behind the larynx, extending from
the base of the tongue to the esophagus. It is the critical dividing point
where foods and fluids are separated from air. At this point, the
passageway divides into the larynx and the esophagus.
Larynx
The larynx is the voice box and is located above the trachea,
just below the throat at the base of the tongue. It is controlled by the
recurrent laryngeal nerves. The larynx is composed of several
cartilages. The thyroid cartilage is the largest and is commonly called
the Adams apple. The cricoid cartilage, which contains the vocal
cords, lies below the thyroid cartilage. The cricothyroid membrane is
located below the level of the vocal cords and joins the thyroid and
cricoid cartilages. This site is used in an emergency for access to the
lower airways. In this procedure, called a cricothyroidotomy, an
opening is made between the thyroid and cricoid cartilage and results
in a tracheostomy. The two arytenoid cartilages work with the thyroid
46

cartilage in vocal cord movement. Inside the larynx are two pairs of
vocal cords: the false vocal cords and the true vocal cords. The glottis
is the opening between the true vocal cords. The epiglottis is a leafshaped, elastic structure that is attached along one edge to the top of
the larynx. Its hingelike action prevents food from entering the trachea
(aspiration) by closing over the glottis during swallowing. The epiglottis
opens during breathing and coughing.
2. Lower Respiratory Tract
Airways
The lower airways are the trachea; two mainstem bronchi; lobar,
segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and
alveoli. The lower respiratory tract (tracheobronchial tree) is an
inverted treelike structure consisting of muscle, cartilage, and elastic
tissues. This system of branching tubes, which decrease in size from
the trachea to the respiratory bronchioles, allows gases to move to and
from the lungs. Gas exchange takes place in the lung tissue between
the alveoli and the lung capillaries, not in the airways.
The trachea (windpipe) is located in front of the esophagus. It
begins at the lower edge of the cricoid cartilage of the larynx and
extends to the level of the fourth or fifth thoracic vertebra. The trachea
branches into the right and left mainstem bronchi at a junction called
the carina. The trachea contains 6 to 10 C-shaped rings of cartilage.

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The open portion of the C is the back portion of the trachea and
contains smooth muscle that is shared with the esophagus.
The mainstem bronchi, or primary bronchi, begin at the carina.
The bronchus is similar in structure to the trachea. The right bronchus
is slightly wider, shorter, and more vertical than the left bronchus.
Because of these differences, the right bronchus can be accidentally
intubated when an endotracheal tube is passed. Also, when a foreign
object is aspirated from the throat, it usually enters the right bronchus.
The mainstem bronchi branch into the secondary (lobar) bronchi that
enter each of the five lobes of the two lungs. Each lobar bronchus
branches into progressively smaller divisions.
The cartilage of these lobar bronchi is ring-shaped and resist collapse.
The bronchi are lined with a ciliated, mucussecreting membrane. The
cilia move mucus up and away from the lower airway to the trachea,
where the mucus is either spit out or swallowed.
The bronchioles branch from the secondary bronchi and divide
into smaller and smaller tubes, which are the terminal and respiratory
bronchioles These tubes have a small diameter, have no cartilage, and
depend entirely on the elastic recoil of the lung to remain open.
Alveolar ducts with alveoli attached branch from the respiratory
bronchioles and resemble a bunch of grapes. Alveolar sacs arise from
these ducts. The alveolar sacs contain groups of alveoli, which are the
basic units of gas exchange A pair of healthy adult lungs has about 290
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million alveoli, which are surrounded by lung capillaries. These

numerous small alveoli share common walls, making a large surface
area for gas exchange. In a healthy adult, this surface area is about the
size of a tennis court. Acinus is a term for the structural unit
consisting of a respiratory bronchiole, an alveolar duct, and an alveolar
sac.
The alveolar walls have cells called type II pneumocytes that secrete
surfactant, a fatty protein that reduces surface tension in the alveoli.
Without

surfactant,

atelectasis

(alveolar

collapse)

occurs.

In

atelectasis, gas exchange is reduced because alveolar surface area is

reduced.
Lungs
The lungs are elastic, cone-shaped organs located in the pleural cavity
in the chest. The apex (top) of each lung extends above the clavicle;
the base (bottom) of each lung lies just above the diaphragm. The
lungs are composed of millions of alveoli and their related ducts,
bronchioles, and bronchi. The
right lung, which is larger than the left, is divided into three lobes:
upper, middle, and lower. The left lung, which is narrower and smaller
than the right lung, is divided into only two lobes. About 60% to 65% of
lung function occurs in the right lung. Any problem with the right lung
interferes with oxygenation to a greater degree than a problem in the
left lung.
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The pleura is a continuous smooth membrane composed of two

surfaces that totally enclose the lungs. The parietal pleura lines the
inside of the chest cavity and the upper surface of the diaphragm. The
visceral pleura covers the lung surfaces. These two surfaces are
lubricated by a thin fluid produced by the cells lining the pleura. This
fluid allows the surfaces to glide across each other smoothly and
painlessly
during breathing. Blood flow in the lungs occurs through two separate
systems: bronchial and pulmonary. The bronchial system carries the
blood needed to meet the metabolic demands of the lungs. The
bronchial arteries, which branch from the thoracic aorta, are part of the
systemic circulation and do not
participate in gas exchange.
The pulmonary circulation is a highly vascular capillary network.
Oxygen-poor blood travels from the right ventricle of the heart into the
pulmonary artery, which eventuallybranches into arterioles that form
capillary networks. These capillaries are meshed around and through
the alveolithe
site of gas exchange. Freshly oxygenated blood travels from the
capillaries to the pulmonary veins and then to the left atrium. From the
left atrium, oxygenated blood flows into the left ventricle, where it is
pumped throughoutthe systemic circulation.

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B. REVIEW OF ANATOMY AND PHYSIOLOGY OF THE NERVOUS

SYSTEM
The brain is a spongy organ made up of nerve and supportive
tissues. It is located in the head and is protected by a bony covering
called the skull. The base, or lower part, of the brain is connected to
the spinal cord. Together, the brain and spinal cord are known as the
central nervous system (CNS). The spinal cord contains nerves that
send information to and from the brain.

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The CNS works with the peripheral nervous system (PNS). The PNS
is made up of nerves that branch out from the spinal cord to relay
messages from the brain to different parts of the body. Together, the
CNS and PNS allow a person to walk, talk, throw a ball and so on.
Structure and function of the brain:
The brain is the bodys control centre. It constantly receives and
interprets nerve signals from the body and responds based on this
information. Different parts of the brain control movement, speech,
emotions, consciousness and internal body functions, such as heart
rate, breathing and body temperature.
The brain has 3 main parts: cerebrum, cerebellum and brain stem.

52

Cerebrum
The cerebrum is the largest part of the brain. It is divided into 2
parts (halves) called the left and right cerebral hemispheres. The 2
hemispheres are connected by a bridge of nerve fibres called the
corpus callosum.
The right half of the cerebrum (right hemisphere) controls the left
side of the body. The left half of the cerebrum (left hemisphere)
controls the right side of the body.
The outer surface of the cerebrum is called the cerebral cortex or
grey matter. It is the area of the brain where nerve cells make
connections, called synapses, that control brain activity. The inner area
of the cerebrum contains the insulated (myelinated) bodies of the
nerve cells (axons) that relay information between the brain and spinal
cord. This inner area is called the white matter because the insulation
around the axons gives it a whitish appearance.
The cerebrum is further divided into 4 sections called lobes.
These include the frontal (front), parietal (top), temporal (side) and
occipital (back) lobes.

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Each lobe has different functions:

The frontal lobe controls movement, speech, behaviour, memory,

emotions and intellectual functioning, such as thought processes,
reasoning, problem solving, decision making and planning.

The parietal lobe controls sensations, such as touch, pressure,

pain and temperature. It also controls spatial orientation
(understanding of size, shape and direction).

The temporal lobe controls hearing, memory and emotions. The

left temporal lobe also controls speech.

The occipital lobe controls vision.

Cerebellum

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The cerebellum is the next largest part of the brain. It is located

under the cerebrum at the back of the brain. It is divided into 2 parts or
hemispheres and has grey and white matter, much like the cerebrum.
The cerebellum is responsible for:

movement

posture

balance

reflexes

complex actions (walking, talking)

collecting sensory information from the body

Brain stem
The brain stem is a bundle of nerve tissue at the base of the
brain. It connects the cerebrum to the spinal cord and sends messages
between different parts of the body and the brain.
The brain stem has 3 areas:

midbrain

pons

medulla oblongata

The brain stem controls:

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breathing

body temperature

blood pressure

heart rate

hunger and thirst

Cranial nerves emerge from the brainstem. These nerves control

facial sensation, eye movement, hearing, swallowing, taste and
speech.
Other important parts of the brain
Cerebrospinal fluid (CSF)
The cerebrospinal fluid (CSF) is a clear, watery liquid that surrounds,
cushions and protects the brain and spinal cord. The CSF also carries
nutrients from the blood to, and removes waste products from, the
brain. It circulates through chambers called ventricles and over the
surface of the brain and spinal cord. The brain controls the level of CSF
in the body.
Meninges
The brain and spinal cord are covered and protected by 3 thin layers of
tissue (membranes) called the meninges:

dura mater thickest outer layer

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arachnoid layer middle, thin membrane

pia mater inner, thin membrane

CSF flows in the space between the arachnoid layer and the pia mater.
This space is called the subarachnoid space.
The tentorium is a flap made of a fold in the meninges. It separates the
cerebrum from the cerebellum.

The supratentorial area of the brain is the area above the

tentorium. It contains the cerebrum, the first and second (lateral)
ventricles, the third ventricle, and glands and structures in the
centre of the brain.

The infratentorial area is located at the back of the brain below

the tentorium. It contains the cerebellum and brain stem. This
area is also called the posterior fossa.

Corpus callosum
The corpus callosum is a bundle of nerve fibres between the 2 cerebral
hemispheres. It connects and allows communication between both
hemispheres.
Thalamus
The thalamus is a structure in the middle of the brain that has 2 lobes
or sections. It acts as a relay station for almost all information that
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comes and goes between the brain and the rest of the nervous system
in the body.
Hypothalamus
The hypothalamus is a small structure in the middle of the brain below
the

thalamus.

It

plays

part

in

controlling

body

temperature, hormone secretion, blood pressure, emotions, appetite,

and sleep patterns.
Pituitary gland
The pituitary gland is a small, pea-sized organ in the centre of the
brain. It is attached to the hypothalamus and makes a number of
different hormones that affect other glands of the bodys endocrine
system. It receives messages from the hypothalamus and releases
hormones that control the thyroid and adrenal gland, as well as growth
and physical and sexual development.
Ventricles
The ventricles are fluid-filled spaces (cavities) within the brain. There
are 4 ventricles:

The first and second ventricles are in the cerebral hemispheres.

They are called lateral ventricles.

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The third ventricle is in the centre of the brain, surrounded by the

thalamus and hypothalamus.

The fourth ventricle is at the back of the brain between the brain
stem and the cerebellum.

The ventricles are connected to each other by a series of tubes. The

fluid in the ventricles is cerebrospinal fluid (CSF). The CSF flows
through the ventricles, around the brain in the space between the
layers of the meninges (subarachnoid space) and down the spinal cord.

Pineal gland
The pineal gland is a very small gland in the third ventricle of the brain.
It produces the hormone melatonin, which influences sleeping and
waking patterns and sexual development.
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Choroid plexus
The choroid plexus is a small organ in the ventricles that makes CSF.
Cranial nerves
There are 12 pairs of cranial nerves that perform specific functions in
the head and neck area. The first pair starts in the cerebrum, while the
other 11 pairs start in the brain stem. Cranial nerves are indicated by
number (Roman numeral) or name.
Cranial nerves and their functions
Number Name
I
olfactory
II
optic
III
oculomotor

Function
smell
vision and light detection by the pupil
eye movement upward, downward or inward
narrowing and widening of the pupil

IV
V

VI
VII

trochlear
trigeminal

lifting of the eyelid

eye movement downward and inward
facial sensation

abducens
facial

chewing
outward eye movement
facial expression
closing of the eyelid

VIII

acoustic

taste in the front part of the tongue

hearing
balance
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IX

glossopharyngea swallowing
l

vagus

gag reflex
speech
swallowing
gag reflex
speech (vocal cords)

XI

XII

accessory

control of muscles in internal organs

neck turning

hypoglossal

shoulder shrugging
tongue movement

Blood-brain barrier
The blood-brain barrier is a specialized system of blood vessels
and enzymes that protect the brain from chemicals or toxins produced
by bacteria. It helps maintain a constant environment for the brain.
The blood-brain barrier is made up of very small blood vessels
(capillaries) that are lined with thin, flat endothelial cells. In other parts
of the body, endothelial cells have small spaces between them that
allow substances to move in and out of the capillary so they can reach
other cells and tissues. In the brain, the endothelial cells are packed
tightly together so substances cannot pass out of the bloodstream into
the brain. The enzymes also restrict the types of substances that can
be carried from the bloodstream into the brain.

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Some substances can pass through the blood-brain barrier, such as

very small molecules and molecules that can be dissolved in fat (are
lipid soluble).
Types of cells in the brain
Neurons
Neurons are the basic unit of the nervous system. All cells of the
nervous system are comprised of neurons. The nervous system can be
divided into two parts: the central nervous system and the peripheral
nervous system. The central nervous system consists of the brainand
spinal cord, while the peripheral nervous system consists of sensory
and motor nervous cells that run throughout the body.
Parts Of A Neuron
A neuron consists of two major parts:

Cell Body
Neurons contain the same cellular components as other body cells. The
central cell body is the largest part of a neuron and contains the
neuron's nucleus, associatedcytoplasm, and other cell structures. The
cell body produces proteins needed for the construction of other parts
of

the

neuron.

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Nerve Processes
Nerve processes are "finger-like" projections from the cell body that are
able to conduct and transmit signals. There are two types:
Axons - typically carry signals away from the cell body. They are long
nerve processes that may branch out to convey signals to various
areas. Some axons are wrapped in an insulating coat of glial
cells called oligodendrocytes and Schwann cells. These cells form the
myelin sheath which indirectly assists in the conduction of impulses as
myelinated nerves can conduct impulses quicker than unmyelinated
ones. Axons end at junctions known as synapses.
Dendrites - typically carry signals toward the cell body. Dendrites are
usually more numerous, shorter and more branched than axons. They
have many synapses in order to receive signal messages from nearby
neurons.
Neurons: Nerve Impulse
Axons and dendrites are bundled together into what are called nerves.
These nerves send signals between the brain, spinal cord, and other
body organs via nerve impulses. Nerve impulses are received at the
neuronal dendrites and are carried along the axon to the terminal
branches. These branches end at a junction called a synapse. It is at
the synapse where chemical or electrical impulses must cross the gap
and be carried to the dendrites of adjacent cells. At electrical synapses,
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ions and other molecules pass through gap junctions allowing for the
passive transmission of electrical signals from one cell to the other. At
chemical synapses, chemical signals called neurotransmitters are
released which cross the gap junction to stimulate the next neuron.
Neuron Classification
Neurons are classified as either motor, sensory, or interneurons.Motor
neuronscarry information from the central nervous system to organs,
glands, and muscles.Sensory neuronssend information to the central
nervous

system

from

stimuli.Interneuronsrelay

internal
signals

organs
between

or
motor

from
and

external
sensory

neurons.

The brain is made up of neurons and glial cells:

64

neurons
o These cells carry the signals that make the nervous system
work.
o They cannot be replaced or repaired if they are damaged.

glial cells (neuroglial cells)

o These cells support, feed and protect the neurons.
o The different types of glial cells are:

astrocytes

oligodendrocytes

ependymal cells

microglial cells

Structure and function of the spine

The spine is made up of:

vertebrae, sacrum and coccyx bony sections that house and

protect the spinal cord (commonly called the spine)
o The vertebral body is the biggest part of a vertebra. It is
the front part of the vertebra, which means it faces into the
body.

spinal cord a column of nerves inside the protective vertebrae

that runs from the brain to the bottom of the spine

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disc a layer of cartilage between each vertebra that cushions

and protects the vertebrae and spinal cord

The spine is divided into 5 sections:

cervical the vertebrae from the base of the skull to the lowest
part of the neck

thoracic the vertebrae from the shoulders to mid-back

lumbar the vertebrae from mid-back to the hips

sacrum the vertebrae at the base of the spine

o The vertebrae in this section are fused and do not flex.

coccyx the tail bone at the end of the spine

o The vertebrae in this section are fused and do not flex.

Spinal nerves

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The spine relays messages between the body and the brain. These
nerve messages control body functions like movement, bladder and
bowel control and breathing. Each vertebra has a pair of spinal nerves
that receive messages from the body (sensory impulses) and send
messages to the body (motor impulses). The spinal nerves are
numbered from the cervical spine to the sacral spine.
Spinal nerves and their functions
Numbe Part of
r
C1

Function

spine
to cervical send messages to the back of the head, neck,

C8

shoulders, arms, hands and diaphragm

(8
pairs)
T1
to thoracic send messages to the chest, some back muscles and
T12

parts of the abdomen

(12
pairs)
L1
to lumbar send messages to the lower parts of the abdomen and
L5
(5

the back, some of the legs and some parts of the

external genital organs

pairs)
S1
to sacral

send messages to the thighs, lower parts of the legs,

S5

feet, most of the external genital organs, the groin

area, the bladder and the anal sphincter
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(5
pairs)

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