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16.1: Case Study: Respiratory System and Gas Exchange

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• Page ID 16816

• Suzanne Wakim & Mandeep Grewal
• Butte College

Case Study: Cough That Won't Quit

Three weeks ago, 20-year-old Sacheen came down with symptoms typical of the common cold. She had a runny nose, fatigue, and a mild cough. Her symptoms had been starting to improve, but recently her cough has been getting worse. She coughs up a lot of thick mucus, her throat is sore from frequent coughing, and her chest feels very congested. According to her wife, Sacheen has a “chest cold.” Sacheen is a smoker and wonders if her habit is making her cough worse. She decides that it is time to see a doctor.

Dr. Tsosie examines Sacheen and asks about her symptoms and health history. She checks the level of oxygen in Sacheen’s blood by attaching a device called a pulse oximeter to Sacheen’s finger (Figure \(\PageIndex{2}\)). Dr. Tsosie concludes that Sacheen has bronchitis, an infection that commonly occurs after a person has a cold or flu. Bronchitis is sometimes referred to as a “chest cold,” so Sacheen’s wife was right! Bronchitis causes inflammation and a build-up of mucus in the bronchial tubes in the chest.

Because viruses, and not bacteria, usually cause bronchitis, Dr. Tsosie tells Sacheen that antibiotics are not likely to help. Instead, she recommends that Sacheen try to thin and remove the mucus by drinking plenty of fluids and using a humidifier, or spending time in a steamy shower. She also recommends that Sacheen get plenty of rest.

Dr. Tsosie also tells Sacheen some things not to do—most importantly, not to smoke while she is sick and to try to quit smoking in the long term. She explains that smoking can make people more susceptible to bronchitis and can hinder recovery. She also advises Sacheen not to take over-the-counter cough suppressant medication.

As you read this chapter on the respiratory system, you will better understand what bronchitis is and why Dr. Tsosie made the treatment recommendations that she did. At the end of the chapter, you will learn more about acute bronchitis, which is the type that Sacheen has. This information may come in handy to you personally because the chances are high that you will get this common infection at some point in your life—there are millions of bronchitis cases every year!

Chapter Overview: Respiratory System

In this chapter, you will learn about the respiratory system, the system that exchanges gases such as oxygen and carbon dioxide between the body and the outside air. Specifically, you will learn about:

• The process of respiration, in which oxygen moves from the outside air into the body and carbon dioxide and other waste gases move from inside the body into the outside air.
• The organs of the respiratory system, including the lungs, bronchial tubes, and the rest of the respiratory tract.
• How the respiratory tract protects itself from pathogens and other potentially harmful substances in the air.
• How the rate of breathing is regulated to maintain homeostasis of blood gases and pH.
• How ventilation, or breathing, allows us to inhale air into the body and exhale air out of the body.
• The conscious and unconscious control of breathing.
• Nasal breathing compared to mouth breathing.
• What happens when a person is drowning.
• How gas exchange occurs between the air and blood in the alveoli of the lungs, and between the blood and cells throughout the body.
• Disorders of the respiratory system, including asthma, pneumonia, chronic obstructive pulmonary disease (COPD), and lung cancer.
• The negative health effects of smoking.

As you read the chapter, think about the following questions:

• Where are the bronchial tubes, and what is their function?
• What is the function of mucus, and why can too much mucus be a bad thing?
• Why did Dr. Tsosie check Sacheen’s blood oxygen level?
• Why do you think Dr. Tsosie warned Sacheen not to take cough suppressant medications?
• How does acute bronchitis compare to chronic bronchitis, and how do they both relate to smoking?

Attributions

• Coughing by GabboT, CC BY-SA 2.0 , via Wikimedia Commons
• Wrist oximeter by UusiAjaja, public domain via Wikimedia Commons
• Text adapted from Human Biology by CK-12 licensed CC BY-NC 3.0

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Case study: 60-year-old female presenting with shortness of breath.

Deepa Rawat ; Sandeep Sharma .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath.  Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep.

She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea.

She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that are new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath.

There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.

Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity.  Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.

Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Physical Exam

Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2 saturation 90% on room air.

Constitutional:  Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.

HEENT: 

• Head: Normocephalic and atraumatic
• Mouth: Moist mucous membranes 
• Macroglossia
• Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
• Neck: Neck supple. No JVD present. No masses or surgical scarring. 
• Throat: Patent and moist

Cardiovascular:  Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities.

Pulmonary/Chest:  No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. The patient was barely able to finish a full sentence due to shortness of breath.

Abdominal:  Soft. Obese. Bowel sounds are normal. No distension and no tenderness

Skin: Skin is very dry

Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses

• Initial Evaluation

Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate the presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.

Largely unremarkable and non-contributory to establish a diagnosis.

Showed creatinine elevation above baseline from 1.08 base to 1.81, indicating possible acute injury. EGFR at 28 is consistent with chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin, this corrected to 9.8 mg/dL. Mild transaminitis is present as seen in alkaline phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.

Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air, indicating respiratory alkalosis with hypoxic respiratory features.

Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure and acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is determined.

Influenza A and B: Negative

Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.

Chest X-ray

Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings were noted. Small bilateral pleural effusions

Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right

• Differential Diagnosis
• Acute on chronic COPD exacerbation
• Acute on chronic renal failure
• Bacterial pneumonia
• Congestive heart failure
• Pericardial effusion
• Hypothyroidism
• Influenza pneumonia
• Pulmonary edema
• Pulmonary embolism
• Confirmatory Evaluation

On the second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion, the patient's husband provided further history. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills.”

Testing was performed to include TSH, free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion, and any hypokinetic area.

• TSH: 112.717 (H)
• Free T4: 0.56 (L)
• TSH and Free T4 values indicate severe primary hypothyroidism. 

BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, African American patients with more excretion may have falsely low values secondary to greater excretion of BNP. This test is not that helpful in renal failure due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release.

Repeat arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen.

CT chest without contrast was primarily obtained to evaluate the left hemithorax, especially the retrocardiac area.

Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease.

Echocardiogram

The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated.

The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. A dedicated tamponade study was not performed. 

The estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated.

The aortic valve is abnormal in structure and exhibits sclerosis.

The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present.

• Myxedema coma or severe hypothyroidism
• Pericardial effusion secondary to myxedema coma
• COPD exacerbation
• Acute on chronic hypoxic respiratory failure
• Acute respiratory alkalosis
• Bilateral community-acquired pneumonia
• Small bilateral pleural effusions
• Acute mild rhabdomyolysis
• Acute chronic, stage IV, renal failure
• Elevated troponin I levels, likely secondary to Renal failure 
• Diabetes mellitus type 2, non-insulin-dependent
• Extreme obesity
• Hepatic dysfunction

The patient was extremely ill and rapidly decompensating with multisystem organ failure, including respiratory failure, altered mental status, acute on chronic renal failure, and cardiac dysfunction. The primary concerns for the stability of the patient revolved around respiratory failure coupled with altered mental status. In the intensive care unit (ICU), she rapidly began to fail BiPAP therapy. Subsequently, the patient was emergently intubated in the ICU.  A systemic review of therapies and hospital course is as follows:

Considering the primary diagnosis of myxedema coma, early supplementation with thyroid hormone is essential. Healthcare providers followed the American Thyroid Association recommendations, which recommend giving combined T3 and T4 supplementation; however, T4 alone may also be used. T3 therapy is given as a bolus of 5 to 20 micrograms intravenously and continued at 2.5 to 10 micrograms every 8 hours. An intravenous loading dose of 300 to 600 micrograms of T4 is followed by a daily intravenous dose of 50 to 100 micrograms. Repeated monitoring of TSH and T4 should be performed every 1 to 2 days to evaluate the effect and to titrate the dose of medication. The goal is to improve mental function. Until coexistent adrenal insufficiency is ruled out using a random serum cortisol measurement, 50 to 100 mg every 8 hours of hydrocortisone should be administered. In this case, clinicians used hydrocortisone 100 mg IV every 8 hours. Dexamethasone 2 to 4 mg every 12 hours is an alternative therapy.

The patient’s mental status rapidly worsened despite therapy. In the setting of her hypothyroidism history, this may be myxedema coma or due to the involvement of another organ system. The thyroid supplementation medications and hydrocortisone were continued. A CT head without contrast was normal.

Respiratory

For worsening metabolic acidosis and airway protection, the patient was emergently intubated. Her airway was deemed high risk due to having a large tongue, short neck, and extreme obesity. As the patient’s heart was preload dependent secondary to pericardial effusion, a 1-liter normal saline bolus was started. Norepinephrine was started at a low dose for vasopressor support, and ketamine with low dose Propofol was used for sedation. Ketamine is a sympathomimetic medication and usually does not cause hypotension as all other sedatives do. The patient was ventilated with AC mode of ventilation, tidal volume of 6 ml/kg ideal body weight, flow 70, initial fio2 100 %, rate 26 per minute (to compensate for metabolic acidosis), PEEP of 8.

Cardiovascular

She was determined to be hemodynamically stable with a pericardial effusion. This patient’s cardiac dysfunction was diastolic in nature, as suggested by an ejection fraction of 66% to 70%. The finding of posterior pericardial effusion further supported this conclusion. The posterior nature of this effusion was not amenable to pericardiocentesis. As such, this patient was preload dependent and showed signs of hypotension. The need for crystalloid fluid resuscitation was balanced against the impact increased intravascular volume would have on congestive heart failure and fluid overload status. Thyroid hormone replacement as above should improve hypotension. However, vasopressor agents may be used to maintain vital organ perfusion targeting a mean arterial pressure of greater than 65 mm Hg as needed. BP improved after fluid bolus, and eventually, the norepinephrine was stopped. Serial echocardiograms were obtained to ensure that the patient did not develop tamponade physiology. Total CK was elevated, which was likely due to Hypothyroidism compounded with chronic renal disease.

Infectious Disease

Blood cultures, urine analysis, and sputum cultures were obtained. The patient's white blood cell count was normal. This is likely secondary to her being immunocompromised due to hypothyroidism and diabetes. In part, the pulmonary findings of diffuse edema and bilateral pleural effusions can be explained by cardiac dysfunction. Thoracentesis of pleural fluid was attempted, and the fluid was analyzed for cytology and gram staining to rule out infectious or malignant causes as both a therapeutic and diagnostic measure. Until these results return, broad-spectrum antibiotics are indicated and may be discontinued once the infection is ruled out completely.

Gastrointestinal

Nasogastric tube feedings were started on the patient after intubation. She tolerated feedings well. AST and ALT were mildly elevated, which was thought to be due to hypothyroidism, and as the TSH and free T4 improved, her AST and ALT improved. Eventually, these values became normal once her TSH level was close to 50.

Her baseline creatinine was found to be close to 1.08 in prior medical records. She presented with a creatinine of 1.8 in the emergency department. Since hypothyroidism causes fluid retention in part because thyroid hormone encourages excretion of free water and partly due to decreased lymphatic function in returning fluid to vascular circulation.  Aggressive diuresis was attempted. As a result, her creatinine increased initially but improved on repeated evaluation, and the patient had a new baseline creatinine of 1.6. Overall she had a net change in the fluid status of 10 liters negative by her ten days of admission in the ICU.

Mildly anemic otherwise, WBC and platelet counts were normal. Electrolyte balance should be monitored closely, paying attention to sodium, potassium, chloride, and calcium specifically as these are worsened in both renal failure and myxedema. 

Daily sedation vacations were enacted, and the patient's mental status improved and was much better when TSH was around 20. The bilateral pleural effusions improved with aggressive diuresis. Breathing trials were initiated when the patient's fio2 requirements decreased to 60% and a PEEP of 8. She was eventually extubated onto BiPAP and then high-flow nasal cannula while off of BiPAP. Pericardial fluid remained stable, and no cardiac tamponade pathology developed. As a result, it was determined that a pericardial window was unnecessary. Furthermore, she was not a candidate for pericardiocentesis as the pericardial effusion was located posterior to the heart. Her renal failure improved with improved cardiac function, diuretics, and thyroid hormone replacement.

After extubation patient had speech and swallow evaluations and was able to resume an oral diet. The patient was eventually transferred out of the ICU to the general medical floor and eventually to a rehabilitation unit.

Despite the name myxedema coma, most patients will not present in a coma status. This illness is at its core a severe hypothyroidism crisis that leads to systemic multiorgan failure. Thyroid hormones T3, and to a lesser extent, T4 act directly on a cellular level to upregulate all metabolic processes in the body. Therefore, deficiency of this hormone is characterized by systemic decreased metabolism and decreased glucose utilization along with increased production and storage of osmotically active mucopolysaccharide protein complexes into peripheral tissues resulting in diffuse edema and swelling of tissue. [1]

Myxedema coma is an illness that occurs primarily in females at a rate of 4:1 compared to men. It typically impacts the elderly at the age of greater than 60 years old, and approximately 90% of cases occur during the winter months. Myxedema coma is the product of longstanding unidentified or undertreated hypothyroidism of any etiology. Thyroid hormone is necessary throughout the body and acts as a regulatory hormone that affects many organ systems. [2] In cardiac tissues, myxedema coma manifests as decreased contractility with subsequent reduction in stroke volume and overall cardiac output.  Bradycardia and hypotension are typically present also. Pericardial effusions occur due to the accumulation of mucopolysaccharides in the pericardial sac, which leads to worsened cardiac function and congestive heart failure from diastolic dysfunction. Capillary permeability is also increased throughout the body leading to worsened edema. Electrocardiogram findings may include bradycardia and low-voltage, non-specific ST waveform changes with possible inverted T waves.

Neurologic tissues are impacted in myxedema coma leading to the pathognomonic altered mental status resulting from hypoxia and decreased cerebral blood flow secondary to cardiac dysfunction as above. Additionally, hypothyroidism leads to decreased glucose uptake and utilization in neurological tissue, thus worsening cognitive function.

The pulmonary system typically manifests this disease process through hypoventilation secondary to the central nervous system (CNS) depression of the respiratory drive with blunting of the response to hypoxia and hypercapnia. Additionally, metabolic dysfunction in the muscles of respiration leads to respiratory fatigue and failure, macroglossia from mucopolysaccharide driven edema of the tongue leads to mechanical obstruction of the airway, and obesity hypoventilation syndrome with the decreased respiratory drive as most hypothyroid patients suffer from obesity.

Renal manifestations include decreased glomerular filtration rate from the reduced cardiac output and increased systemic vascular resistance coupled with acute rhabdomyolysis lead to acute kidney injury. In the case of our patient above who has a pre-existing renal disease status post-nephrectomy, this is further worsened.  The net effect is worsened fluid overload status compounding the cardiac dysfunction and edema. [3]

The gastrointestinal tract is marked by mucopolysaccharide-driven edema as well leading to malabsorption of nutrients, gastric ileus, and decreased peristalsis. Ascites is common because of increased capillary permeability in the intestines coupled with coexistent congestive heart failure and congestive hepatic failure. Coagulopathies are common to occur as a result of this hepatic dysfunction.

Evaluation: The diagnosis of myxedema coma, as with all other diseases, is heavily reliant on the history and physical exam. A past medical history including hypothyroidism is highly significant whenever decreased mental status or coma is identified. In the absence of identified hypothyroidism, myxedema coma is a diagnosis of exclusion when all other sources of coma have been ruled out. If myxedema coma is suspected, evaluation of thyroid-stimulating hormone (TSH), free thyroxine (T4), and serum cortisol is warranted. T4 will be extremely low. TSH is variable depending on the etiology of hypothyroidism, with a high TSH indicating primary hypothyroidism and a low or normal TSH indicating secondary etiologies. Cortisol may be low indicating adrenal insufficiency because of hypothyroidism.  [4]

Prognosis: Myxedema coma is a medical emergency. With proper and rapid diagnosis and initiation of therapy, the mortality rate is still as high as 25% to 50%. The most common cause of death is due to respiratory failure. The factors which suggest a poorer prognosis include increased age, persistent hypothermia, bradycardia, low score Glasgow Coma Scale, or multi-organ impairment indicated by high APACHE (Acute Physiology and Chronic Health Evaluation) II score. For these reasons, placement in an intensive care unit with a low threshold for intubation and mechanical ventilation can improve mortality outcomes. [3] [5]

• Pearls of Wisdom
• Not every case of shortness of breath is COPD or congestive heart failure (CHF). While less likely, a history of hypothyroidism should raise suspicion of myxedema coma in a patient with any cognitive changes.
• Myxedema is the great imitator illness that impacts all organ systems. It can easily be mistaken for congestive heart failure, COPD exacerbation, pneumonia, renal injury or failure, or neurological insult.
• Initial steps in therapy include aggressive airway management, thyroid hormone replacement, glucocorticoid therapy, and supportive measures.
• These patients should be monitored in an intensive care environment with continuous telemetry. [6]
• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis, particularly in more challenging cases such as this one. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

• Review Questions
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Case Study of 60 year old female presenting with Shortness of Breath Contributed by Sandeep Sharma, MD

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Rawat D, Sharma S. Case Study: 60-Year-Old Female Presenting With Shortness of Breath. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Creating Model Working Lungs: Just Breathe

Hands-on Activity Creating Model Working Lungs: Just Breathe

Grade Level: 5 (3-5)

Time Required: 45 minutes

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Group Size: 2

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Associated Informal Learning Activity: Creating Model Lungs: Just Breathe!

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By studying the respiratory system, engineers have created technologies such as the heart-lung machine, which keeps patients alive during heart transplants. Engineers are currently working on creating an implantable, artificial lung to aid people with serious lung diseases. One way that engineers study complicated systems is by creating models, similar to how students create their own model lungs in this activity.

After this activity, students should be able to:

• Describe the function of the respiratory system.
• Create a model of the lungs and explain what happens to them when you inhale and exhale.
• Give examples of engineering advancements that have helped with respiratory systems.

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Each group needs:

• 2-liter empty plastic bottle with cap
• 2 plastic drinking straws; available inexpensively at restaurant supply stores or donated by fast-food chains; do not use the flexible drinking straws
• 2 9-inch balloons
• 1 larger balloon; for example, for a punch ball
• 2 rubber bands
• Lung Worksheet , one per student

Have you ever been on a crowded subway or bus? You probably could not wait to get out where there were not so many people and you could move around freely. This is similar to the process that causes air to flow in and out of your lungs. The air molecules are either crowded outside (in the environment) and want to get into the lungs where there are less air molecules (inhalation), or they want to get outside because they are too crowded inside the lungs (exhalation).

When you inhale, your diaphragm muscle contracts downward and rib muscles pull upward causing air to fill the lungs. Can you think of why? Well, when your diaphragm moves down and ribs move up, they make more space in your chest (in the thoracic cavity) for air. This also decreases the pressure on your lungs so the air will flow in from the outside. The opposite happens when you breathe out. Your diaphragm relaxes and the ribs and lungs push in which causes air to be pushed out.

Engineers need to understand the respiratory process in order to design machines and medicines to help people whose respiratory systems function incorrectly or with difficulty. Have you ever known someone who suffers from asthma or pneumonia? Well, chemical engineers design devices and medicines, such as inhalers filled with an adrenergic bronchodilator to help people breathe better. Engineers have also developed artificial lungs that help people breathe while fighting off infections. And engineers also design the systems that help astronauts breathe easily during space flight, when they are far away from the Earth's atmosphere.

Engineers use models to study complicated processes and better understand them. In this activity, you will act like engineers by building models of the lungs in order to study the breathing process and what happens when you breathe in and out.

Before the Activity

• Gather materials and make copies of the Lung Worksheet .
• In each of the 2-liter bottle caps, drill 2 holes that are just big enough for a drinking straw to fit through. Tip: Make sure to drill the holes far enough apart that the holes do not become one big hole!
• Using a pair of scissors, cut off the bottom of each 2-liter bottle.

With the Students

• Peel off the labels, if any, on the 2-liter bottles.
• Tell students that the 2-liter bottle represents the human chest cavity.
• Stick two drinking straws through the two holes in the bottle cap.
• Place one 9-inch balloon on the end of each straw and secure them with rubber bands, as shown in Figure 2.

• Tell students that the straws represent the bronchi and the balloons represent the lungs.
• Stick the balloon ends of the straws through the bottle opening and tightly screw on the lid.
• Stretch out the larger balloon and place it over the open bottom of the bottle.
• Tell students that this larger balloon represents the diaphragm. Now they have a finished model of the lungs! (See Figure 3,) Next, it is time to make the lungs work!

• Pull the diaphragm (balloon) down (that is, away from the lungs) in order to inflate the lungs. (Note: This makes the chest cavity larger and decreases the pressure.)
• Push the diaphragm (balloon) in (towards the lungs) in order to deflate the lungs. (Note: This makes the chest cavity smaller and increases the pressure.)

• Have students complete the worksheet.
• To conclude, have teams make presentations of their model lungs, as described in the Assessment section.

bronchi: Two large tubes connected to the trachea that carry air to and from the lungs.

diaphragm: A shelf of muscle extending across the bottom of the rib cage.

lungs: Spongy, saclike respiratory organs that occupy the chest cavity, along with the heart. They provide oxygen to the blood and remove carbon dioxide from it.

Pre-Activity Assessment

Discussion Questions: Solicit, integrate and summarize student responses.

• How do the lungs work? How do you inhale and exhale?
• Does your breathing change when you exercise? How?

Activity Embedded Assessment

Worksheet: Have students record their observations and complete the Lung Worksheet . Review their answers to gauge their mastery of the subject.

Post-Activity Assessment

Presentation and Informal Discussion: Have one or more groups use their projects to demonstrate how the lungs work. Next, hypothesize with the class: What would happen to the respiratory system if we punctured it? Have one group puncture the cavity (bottle) or diaphragm (rubber bottom) and demonstrate what happens to the lungs if this body part is damaged. (Answer: The lungs are unable to inflate and/or deflate if the chest cavity has a leak. The lungs cannot maintain the pressure difference.) Discuss with the class: What could engineers do to help fix a puncture in a person's lungs?

When cutting off the plastic bottle bottom, make sure that the edges are as smooth as possible so it does not rip the balloon on the bottom. If edges are rough, bind them with masking or duct tape.

Seal any potential leaks with poster tack.

Have students research respiratory diseases and how they affect the function of the respiratory system. Can they alter their model to show what happens to the lungs with these diseases? Can they demonstrate on their models what has been done to help people with respiratory problems?

Engineers have developed an artificial lung to help people fight infection. The artificial lung is approximately 18-inches long and consists of membranes that pass oxygen to the blood and remove carbon dioxide. It is inserted through a vein in the leg and lodged in the main vein (the vena cava) passing blood to the heart. The blood is re-oxygenated through a catheter attached to an oxygen supply. Have students create a drawing of a machine that could help their model lungs "breathe" without having them pull down or push up on the lower balloon. Explain that this is how engineers might begin to develop life-saving machines.

For lower grades, have students make one lung rather than two. Use a smaller water bottle rather than a 2-liter bottle and one balloon lung rather than two.

Students learn about the parts of the human respiratory system and the gas exchange process that occurs in the lungs. They also learn about the changes in the respiratory system that occur during spaceflight, such as decreased lung capacity.

Students are introduced to the respiratory system, the lungs and air. They learn about how the lungs and diaphragm work, how air pollution affects lungs and respiratory functions, some widespread respiratory problems, and how engineers help us stay healthy by designing machines and medicines that su...

To gain a better understanding of the roles and functions of components of the human respiratory system and our need for clean air, students construct model lungs that include a diaphragm and chest cavity. Student teams design and build a prototype face mask pollution filter and use their model lung...

Students are introduced to the concepts of air pollution, air quality, and climate change. The three lesson parts (including the associated activities) focus on the prerequisites for understanding air pollution. First, students use M&M® candies to create pie graphs that express their understanding o...

"How is Asthma Treated?" Diseases and Conditions Index, National Heart, Lung and Blood Institute, National Institutes of Health, U.S. Department of Human Services. Accessed May 23, 2006. http://training.seer.cancer.gov/anatomy/respiratory

"Bronchi and Bronchial Tree." Training Website: Bronchi, Epidemiology and End Results (SEER) Program, U.S. National Cancer Institute's Surveillance. Accessed May 23, 2006. http://training.seer.cancer.gov/anatomy/respiratory/passages/bronchi.html

"Respiratory system." Wikipedia, The Free Encyclopedia, Wikipedia,com. Accessed May 23, 2006. https://en.wikipedia.org/wiki/Respiratory_system

Contributors

Supporting program, acknowledgements.

The contents of this digital library curriculum were developed under grants from the Fund for the Improvement of Postsecondary Education (FIPSE), U.S. Department of Education and National Science Foundation (GK-12 grant no. 0338326). However, these contents do not necessarily represent the policies of the DOE or NSF, and you should not assume endorsement by the federal government.

Last modified: May 1, 2020

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