TOPIC 3: RESPIRATORY SYSTEM
The effects of ageing on the respiratory system are many, diverse, complex
and often interactive.
There is considerable variability in what might be defined as normal respiratory
function in the elderly, and it can sometimes be difficult to distinguish it from
age-related comorbidity. (=the fact that people who have
a disease or condition also have one or more other diseases or conditions)"1
Each time we breathe, we risk introducing bacteria, chemicals or other irritants
to our respiratory tract in other words, the respiratory system is under
constant attack.
It is little wonder then, that the respiratory system suffers significant declines
in function as a result of the insults it is exposed to throughout a lifetime.
Respiratory function begins to decline from about the age of 25.
The most obvious effect of ageing is a decrease in respiratory reserve capacity.
Any conditions which stress the respiratory system or increase the demands
for gas exchange are likely to cause functional limitations in the aged, as
reserve capacity is not available to cope with these increased demands.
However, as with other systems, respiratory function, in the absence of
significant pathology, will remain adequate to support a full range of normal
activities as we age.
1. AGE RELATED CHANGES IN THE RESPIRATORY SYSTEM
There is a progressive decrease in the volumes of gas that can be moved
through the airways as we age.
There are many factors which contribute to this decline; the most important
are:
increased rigidity of the upper airways (which increases the work of
breathing);
increased rigidity of the chest wall (which decreases the changes in chest
volume which can be achieved);
decreased respiratory muscle mass and strength;
The respiratory muscles must compensate for the increased work of breathing
by increasing the work they do.
1Lalley PM (2013) The ageing respiratory system pulmonary structure, function and neural control.
Respiratory Physiology and Neurobiology. 187:199-210.
Because of the increased work load, the muscles are working at a higher
percentage of their total capacity, and the reserve capacity is decreased.
It also necessitates increased blood flow to the respiratory muscles, leaving
less oxygen to be delivered to other areas.
As a result, exercise capacity may be decreased.
The elastic tissue in the lungs is responsible for providing the force that
deflates the lungs.
The loss of elastic tissue in ageing limits deflation of the lungs, increasing the
amount of air remaining in the lungs (which is known as the residual volume).
An increase in residual volume decreases the efficiency with which the
respiratory muscles function.
The elastic tissue also helps to hold the airways open during expiration.
When elastic tissue is lost, the airways tend to collapse during expiration,
resulting in a limitation to expiratory air flow.
Putting these ideas together, we can conclude that the workload on the
respiratory muscles increases as we age, at a time when the muscles
themselves are becoming less functional.
The ciliated cells which line the upper airways provide an important defence
against infection by removing material that enters the airways, thus preventing
it from entering the lungs.
With age, the cilia become less functional, and the likelihood of respiratory
infection is increased.
Another change that can increase the risk of respiratory disease in the aged is
the decrease in laryngeal function.
The normal larynx seals of the trachea, preventing bacteria from moving into
the airways.
Altered laryngeal function decreases airway protection.
This problem can be made worse by the use of drugs.
Benzodiazepines (e.g. Valium), used to treat sleeping problems are a common
source of problems because they suppress the laryngeal reflex.
Disease in other body systems can also be important.
For example, patients who have had a stroke often have an impaired laryngeal
reflex, and are at increased risk of developing pneumonia.
Age related changes increase the risk of respiratory disease.
There are also changes in the alveoli which decrease the surface area available
for gas exchange, and therefore make it more difficult to control blood gas
levels.
There is a decrease in the pulmonary capillary volume and number.
As a result the delivery of oxygen to the blood (measured as the arterial
oxygen pressure - PaO2) decreases.
This is likely to limit exercise capacity.
Gas exchange is impaired in the aged.
Respiratory control is altered by ageing.
Sensitivity to changes in oxygen and carbon dioxide levels in the blood is
decreased.
This may be due to decreased sensitivity in the chemoreceptors which are
measuring the composition of the blood, or to changes in the respiratory
centre which is controlling ventilation.
The end result is that the respiratory system becomes less responsive to
changes in the levels of oxygen and carbon dioxide in the blood so the ability
of the respiratory system to regulate the levels of these gases in the blood is
decreased.
The phenomenon of dyspnoea (perceived difficulty in breathing), occurs when
blood gases cannot be adequately controlled and is common in older people.
This problem is exacerbated by exercise, or any condition which stresses the
respiratory system.
The ability to control the levels of oxygen and carbon dioxide in the blood is
impaired in the aged.
One age related change that may affect lung function is the kyphosis (stooping)
of people with osteoporosis.
Kyphosis limits the volume of the chest, and limits the respiratory movements
which can be made.
Consequently, gas movement through the respiratory system is limited, and
oxygen delivery to the alveoli decreases.
If less oxygen reaches the alveoli, less oxygen is available to enter the blood.
You can check the effects of kyphosis yourself.
While sitting or standing upright, take a maximum inspiration.
Now stoop forward, repeat the process and compare the amount of gas
movement you can felt occurring.
Explain the relationship between changes in the musculoskeletal system and
changes in respiratory function
Osteoporosis is a common complication of ageing, it results in postural changes
that make breathing more difficult.
It can also result in pain, and fear of falling which limit a person's mobility.
As a result they lose respiratory fitness, and exercise even less.
As a result they lose muscle strength.
The abnormal posture increases the risk of falling.
Fear of falling can further limit mobility and result in further decreases in
pulmonary function.
In addition to posture - related changes in the volume of the chest, the chest
wall stiffens as a result of calcification of the joints of the chest wall.
During normal breathing, movement of the chest wall contributes to the
changes in lung volume that generate gas flow.
Stiffening of the chest results in an increased reliance on the diaphragm to
generate changes in chest volume.
When the diaphragm contracts it moves downwards, compressing the
abdominal contents.
That is why the abdomen moves outwards on inspiration.
Breathing becomes more difficult when people are lying down, as the contents
of the abdomen compress the diaphragm, and limit its downward movement.
Elevating the head of a person in bed using pillows may help them breathe as it
allows gravity to pull the abdominal contents away from the diaphragm.
The following table lists the changes in the principal measurements of lung
function that occur in ageing.
Summary: Changes in pulmonary function with ageing 16,2
1. Decreased expiratory flow rates (forced expiratory volume in 1 second
[FEV1] and forced vital capacity [FVC]).
These changes are indicative of airway narrowing and are commonly
measured in clinical practice to assess lung function.
2. Increase in residual volume (RV) and functional residual capacity (FRC).
These changes indicate that increased volumes of gas remain in the lungs at
the end of expiration.
This decreases the efficiency of breathing.
2 Harrington J. Lee-Chiong T. (2009) Obesity and aging. Clinics in Chest Medicine. 30(3):609-14.
3. Decline in strength of respiratory muscles, including diaphragm.
This is assessed by measuring maximal inspiratory pressure and maximal
expiratory pressure.
4. Reduction in diffusing (=if a gas or liquid diffuses or is diffused in a
substance, it becomes slowly mixed with that substance) capacity for carbon
monoxide.
This indicates decreased gas movement between the alveoli and capillaries.
5. Decline in maximum oxygen consumption (VO2max).
This indicates that the ability of the body to use oxygen is decreased.
6. Decrease in arterial partial pressure of oxygen (PaO2).
8. Reduction in ventilatory responses to hypoxia (=a condition in which not
enough oxygen reaches the bodys tissues) or hypercapnia (=a condition of
abnormally elevated carbon dioxide (CO2) levels in the blood).
9. Blunting (=make something weaker or less effective) in perception of airflow
resistance.
10. Increase in pulmonary compliance (= a measure of the lung's ability to
stretch and expand).
This reflects the loss of elastic tissue in the lungs.
The elastic tissue is important because it facilitates expiration, and helps to
hold the airways open.
The loss of elastic tissue can cause airway narrowing and limit expiration.
11. Reduced pulmonary elastic recoil.
This makes expiration more difficult.
12. Decrease in chest wall compliance.
This indicates that greater muscular effort is required to produce the changes
in thoracic volume necessary to generate gas flow.
Describe how reserve capacity changes with age and explain the factors that
contribute to this change. Are there similarities between the answer to this
question and causes of changes in reserve capacity in the cardiovascular
system?
Just like the situation in the cardiovascular system, reserve capacity in the
respiratory system decreases with age.
The most important changes are structural changes that increase the work that
the respiratory system is required to do.
Just like the situation in the cardiovascular system, these changes may reduce
exercise capacity, resulting in a loss of fitness, and a further decrease in
respiratory function.
In other words there is a snowball effect.
Diseases in the respiratory system can also result in a loss of reserve capacity.
This is similar to the situation in the cardiovascular system.
Some age-related changes increase the risk of disease occurring.
We see a common theme whereby age-related changes and disease worked
together to change the functional capacity of the system.
2. PATHOLOGICAL CHANGES IN THE RESPIRATORY SYSTEM
There are many pathological conditions commonly affect the respiratory
system of older people.
Some of these diseases are related to the insult of smoking.
These diseases include chronic bronchitis and emphysema, which are part of a
syndrome known as chronic obstructive pulmonary disease.
These diseases are most common in smokers, but not all COPD sufferers have
been smokers.
Chronic bronchitis is characterised by increased mucous production which
produces a chronic cough.
The excessive mucous and associated changes to the airways may limit airflow
through the airways.
Emphysema is characterised by the loss of alveolar tissue.
This reduces the area available for gas exchange, and therefore the amount of
oxygen delivered to the blood.
The elastic tissue in the lungs is located in the walls of the alveoli, so alveolar
destruction also causes loss of elastic tissue.
As a result, elastic recoil of the lungs is decreased, and the airways tend to
collapse during expiration (hence the disease causes obstruction).
Another extremely important disease process in the lung is pneumonia.
It is a leading cause of death in the aged.
Usually, there is some underlying abnormality such as decreased function of
the cilia that contributes to the development of the disease.
Influenza can predispose the aged to pneumonia as can the use of drugs which
blunt the laryngeal reflex.
One of the problems associated with pneumonia in the aged is that the
disease often causes atypical signs which may be easily missed.
In particular, cough and fever may be reduced or absent.
Chest radiographs (X rays) are a standard part of the investigation of older
patients as they may be the only way in which pneumonia can be identified in
the absence of specific symptoms and/or the presence of general symptoms
such as delirium.
Chronic long grade pneumonia may result in a failure to thrive (=become, and
continue to be strong, healthy, etc.) and occasionally delirium (=in an excited
state and not able to think or speak clearly, usually because of fever).
Relationship to changes in other body systems
In the previous module you looked at the relationship between cardiovascular
disease and abnormal cognitive function.
There is also a relationship between decreases in pulmonary and cognitive
function.
Longitudinal (=concerning the development of something over a period of
time) changes in cognitive and pulmonary function have been documented,
and recently it has been shown that changes in the respiratory system precede
cognitive disturbances.
Decreased pulmonary function may also contribute to decreases in cognitive
performance via hypoxia, reduced neurotransmitter function, increased
systemic inflammatory processes, or a combination of factors.3
In the cardiovascular system module you looked at the relationship between
changes in cardiovascular function and changes in cognitive function. Is there
a similar relationship between respiratory and cognitive function?
Just like the situation in the cardiovascular system, cognitive changes can be
associated with alterations in respiratory function.
3Emery CF, Finkel D, Pedersen NL (2012) Pulmonary Function as a Cause of Cognitive Aging. Psychological
Science 2012 23: 1024
