(Ebook) The Respiratory System by Andrew Davies and

Carl Moores (Auth.) ISBN 9780702050725, 0702050725

Pdf Download

https://ebooknice.com/product/the-respiratory-system-6614812

★★★★★
4.6 out of 5.0 (31 reviews )

Instant PDF Download

ebooknice.com
 (Ebook) The Respiratory System by Andrew Davies and Carl
Moores (Auth.) ISBN 9780702050725, 0702050725 Pdf Download

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Here are some recommended products that we believe you will be
interested in. You can click the link to download.

(Ebook) Vagabond, Vol. 29 (29) by Inoue, Takehiko ISBN 9781421531489,

1421531488

https://ebooknice.com/product/vagabond-vol-29-29-37511002

(Ebook) Paediatric Respiratory Disease: Parenchymal Diseases by Andrew

Bush, Jane C. Davies ISBN 9781846920868, 1846920868

https://ebooknice.com/product/paediatric-respiratory-disease-
parenchymal-diseases-4571898

(Ebook) 29, Single and Nigerian by Naijasinglegirl ISBN

9781310004216, 1310004218

https://ebooknice.com/product/29-single-and-nigerian-53599780

(Ebook) Boeing B-29 Superfortress ISBN 9780764302725, 0764302728

https://ebooknice.com/product/boeing-b-29-superfortress-1573658
(Ebook) Core Topics in Vascular Anaesthesia by Carl Moores, Alastair
F. Nimmo ISBN 9781107001817, 1107001811

https://ebooknice.com/product/core-topics-in-vascular-
anaesthesia-5231872

(Ebook) The Collected Papers of Bertrand Russell Volume 29: Détente or

Destruction, 1955-57 by Bone, Andrew;Russell, Bertrand ISBN
9780203004555, 9780415358378, 0203004558, 041535837X

https://ebooknice.com/product/the-collected-papers-of-bertrand-
russell-volume-29-detente-or-destruction-1955-57-11776802

(Ebook) Jahrbuch für Geschichte: Band 29 ISBN 9783112622223,

3112622227

https://ebooknice.com/product/jahrbuch-fur-geschichte-band-29-50958290

(Ebook) Harrow County 29 by Cullen Bunn, Tyler Crook

https://ebooknice.com/product/harrow-county-29-53599548

(Ebook) Organometallic Chemistry, Volume 29 by M. Green ISBN

0854043284

https://ebooknice.com/product/organometallic-chemistry-
volume-29-2440106
The Respiratory System
Commissioning Editor: Timothy Horne
Development Editor: Lulu Stader
Project Manager: Janaki Srinivasan Kumar
Designer/Design Direction: Charles Gray
 SyStemS of the Body

The respiratory system

Basic Science and clinical conditions

second edition

Andrew Davies
Sometime Senior Lecturer of Physiology and
MA PhD DSc

Deputy Director Biology Teaching Unit

University of Edinburgh
Edinburgh, UK

Carl Moores
Consultant Anaesthetist
BA BSc MB ChB FRCA

Royal Infirmary of Edinburgh

Edinburgh, UK

Illustrations by Robert Britton

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2010
First Edition Elsevier Limited, 2003.
Second Edition © 2010 Elsevier Limited. All rights reserved.

No part of this publication may be reproduced or transmitted in

any form or by any means, electronic or mechanical, including pho-
tocopying, recording, or any information storage and retrieval sys-
tem, without permission in writing from the publisher. Permissions
may be sought directly from Elsevier’s Rights Department: phone:
(1) 215 239 3804 (US) or (44) 1865 843830 (UK); fax: (44) 1865
853333; e-mail: [email protected]. You may also com-
plete your request online via the Elsevier website at http://www.
elsevier.com/permissions.

ISBN 978-0-7020-3370-4

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of
Congress

Notice
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our knowledge, changes
in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current informa-
tion provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of the practitioner, rely-
ing on their own experience and knowledge of the patient, to make
diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions. To
the fullest extent of the law, neither the Publisher nor the Authors
assume any liability for any injury and/or damage to persons or
property arising out of or related to any use of the material con-
tained in this book.

The Publisher

Typeset by MPS Limited, a Macmillan Company, Chennai, India

www.macmillansolutions.com

Printed in China
The
Publisher’s
policy is to use
paper manufactured
from sustainable forests
Preface

Students of medicine and related vocations frequently providing chapters which the experience of many years
have difficulty in seeing the relevance of preclinical sub- of teaching this subject convinces us are organized and
jects to their final goal of becoming a practitioner. They essential descriptions of that particular aspect of the res-
also have difficulty in integrating these subjects to form a piratory system.
coherent picture of normal function, which is essential if There is no single disease which illustrates all the
the effects of disease are to be understood. aspects of the subject covered in any chapter and so,
In order to address these problems, this book, like rather than choosing a general condition which loosely
others in the Systems of the Body series, adopts an integrat- relates to the subject, we have selected clinical cases
ing approach based upon function. Into the description of which clearly illustrate an important aspect of the subject
normal function and its relation to structure, a description of of that chapter.
the effects of the disruption caused by disease is integrated. To acknowledge that many students using this book
To enable students to learn effectively they must may have had little clinical experience at this early stage
have a good idea of what is expected of them, and what of their course, we have highlighted important terms.
is to be learned should be broken up into manageable These are shown in bold in the text on their first occur-
and coherent parts. These aims are fulfilled by includ- rence and we have provided a Glossary to define those
ing ‘Objectives’ at the beginning of each chapter and by that can be succinctly explained.
Acknowledgements

The authors wish to thank Drs Doris Redhead, Suzanne would also like to thank Dr Pat Warren, University of
Guy and J.T. Murchison, all of whom are from the Edinburgh, for her helpful comments on the manuscript.
Radiology Department, Royal Infirmary, Edinburgh. They
INTRODUCTION 1
Chapter objectives
After studying this chapter you should be able to:

1. Define respiration.

2. Explain the role of respiration in human homeostasis and its disorder

in specific pathology.

3. Explain the interaction between respiration and the circulation.

4. Describe the pivotal role of diffusion in respiration.

5. Give examples of the importance of named physical phenomena in

specific clinical conditions.

6. State the gas laws necessary to measure lung function in specific

tests for disease.

7. Explain the rationale of respiratory symbols.

1
INTRODUCTION

5th century BC which noted the rapid and repeated move-

Introduction
ments of the heart, relegated the function of the lungs to a
sort of radiator, and stated with his usual authority:
The aim of this book is to provide an understanding of
the respiratory system: its structure, function, and the dis- …as the heart might easily be raised to too high
eases and conditions that may affect it. In attempting to a temperature by hurtful irritation (by its rapid
do this we are adopting the philosophy of the new cur- movements) the genii placed the lungs in its
riculum in medicine, which involves bringing to bear on neighbourhood, which adhere to it and fill the
a particular topic all the sciences relevant to that topic. cavity of the thorax, in order that air vessels might
To include in one book all that a student should know moderate the great heat.
about the anatomy, histology, physiology, pharmacology
and medicine of the respiratory system would result in a Galen (130–199 AD), probably more by an accident of
gigantic and intimidating tome. Equally unsatisfactorily, metaphor rather than on any scientific evidence, came
all these subjects could be treated superficially. We have close to describing the true nature of respiration when he
adopted the policy of basing an understanding of the res- compared it to a lamp burning in a gourd:
piratory system on a full description of its physiology and
anatomy, with specific topics of particular clinical impor- When an animal inspires it is, I think, similar to a
tance being expanded upon in terms of clinical sciences. perforated gourd, but when respiration is prevented at
For students to learn effectively, the material they the appropriate place on the trachea, you may compare
must master should be broken down into manageable it to a gourd unperforated and everywhere closed.
portions with a coherent theme: these are the chapters of
If Galen had had the benefit of modern gas analys-
this book, with each theme being based on a particular
ing facilities he would have found even closer parallels
function of the respiratory system.
between breathing and burning, with oxygen (O2) being
Students must also know what is expected of them,
consumed and carbon dioxide (CO2) being produced in
and each chapter is preceded by a list of aims and objec-
both cases.
tive – things you should be able to do when you have
The ‘bottom line’ of an account of the complicated
mastered the material of that chapter. To provide expe-
process of respiration begins with a flow of
rience of that bane of student life, examinations, each
chapter contains questions of the type you might be OXYGEN IN and ends with a flow of CARBON
asked at an undergraduate level. DIOXIDE OUT.

These two flows are the first and final results of the
What is respiration? complex metabolism of the body, and this book describes
the respiratory system that facilitates these flows.
That depends on the context in which you use the word.
Biochemists use it to describe the energy-producing
chemical processes that take place in tissues, cells or even The need for respiration
parts of cells. In this book we will use the physiologist’s
definition, which is ‘An interchange of gases between an One definition of the success of a species of organism, in
organism and its environment’. To all intents and pur- evolutionary terms, is how well it can maintain constant
poses, for human beings this means ‘breathing’ (Latin, the composition of the fluid surrounding its individual
spiro, ‘I breathe’). The movement of air into and out of cells (its internal environment) despite changes in its
the lungs, which most people call breathing, is called by external environment (surroundings getting dryer, colder,
physiologists ventilation. Breathing is brought about by warmer etc.). This process is called homeostasis and
specific structures of the body, including (but not exclu- requires energy. Most of the energy generated by our tis-
sively) the lungs. A description of these structures at a sues is the result of oxidation of food substrates, and this
macroscopic (anatomical) and microscopic (histological) is the reason we need a flow of OXYGEN IN. Neophytes
level helps us to understand the processes of the respi- in physiology often emphasize the role of the respiratory
ratory system and the disruption of these processes and system in providing this oxygen, and certainly an unin-
structures (pathology) that brings about disease. terrupted supply is important, particularly for the nerv-
The part of our environment involved in this ‘inter- ous system, but of more immediate importance is the
change of gases’ mentioned above is of course the air removal of CO2. The word oxygen means ‘acid producer ’
around us, and our need for air must have been obvious (Greek, oxy; acid; gen, to produce), and the major prod-
to even our most distant ancestors. This need is recorded uct of our oxidative metabolism is the acid gas CO2. The
in some very ancient writings. For example, Anaximenes accumulation of CO2 would result in acidification of the
of Miletus (c. 570 BC) observed that air or pneuma (Greek, body fluids. The importance of removing this CO2 can
‘breath’) was essential to life. be demonstrated by rebreathing from a plastic bag for a
What was not clear to the ancients was what the air was few minutes. The unpleasant sensation that forces you to
used for. Aristotle, drawing on theories dating from the stop this rather dangerous experiment is due to over

2 SYSTEMS OF THE BODY

 1

INTRODUCTION
stimulation of the reflex that controls breathing to get rid
of this gas. You will see later (Chapter 8) that CO2 pro- Fluid
1μ
duces its acidic effect by reacting with water to form car-
bonic acid. 0.5 ms 100 μ Tissue
Ventilation of the lungs would not fulfil the needs of
the cells of our bodies if the results of this ventilation did 5s
not diffuse into the blood, which is then carried close to
the cells of the body by the circulation. 10 cm

Diffusion in respiration and the circulation 150 h

The flows of O2 and CO2 into and out of the body take Fig. 1.1 Time course of diffusion over increasing distances. This figure
place as a result of one very basic physical phenomenon: illustrates how the time needed for diffusion to take place increases
diffusion, which results in the movement of molecules in as the distance involved increases. The absolute times shown in this
example would be for a fairly large molecule such as a neurotransmitter.
liquids and gases from regions of high concentration to
regions of lower concentration. Because they are small,
microscopic organisms such as the humble amoeba in its
Inspiration Inspiration Inspiration Inspiration
pond can rely on this phenomenon alone to carry O2 to Expiration Expiration Expiration Expiration
and remove CO2 from its single cell. Multicellular crea-
tures are too large to rely on diffusion alone: the dis- Oxygen pressure
tances gases would have to diffuse are too great, and the in blood leaving
movement of gas therefore too slow to maintain life. the lungs
Although in human beings the same passive mecha-
nism of diffusion alone supplies and removes these Heart
gases from our bodies (there is no active chemical trans- beat
port), the phenomenon of diffusion is maximized by
complicated respiratory and circulatory systems which
accomplish what the pond water does for the amoebae Fig. 1.2 Timing. Because the heart beats so much faster than the
respiratory cycle there is effectively a continuous flow of blood
in providing a supply of and a sink for these gases. The
through the lungs during inspiration and expiration. Expiration is like
lungs promote diffusion by having an enormous surface breath-holding – no fresh air is added, and the composition of blood
area, which is very thin, through which diffusion can leaving the lungs changes accordingly.
take place easily. A surface of over 90 m2 is enclosed in
a lung volume of less than 10 L. This functional 90 m2 is
often reduced in disease, by thickening of the membrane, addition of fresh air to that already in the lungs and
excess fluid in the lungs, or by a reduction in the supply the effects of exchange with the blood passing through
of air or blood. The circulation of the blood forms the the lungs. Expiration in this context is the equivalent of
transport link between the diffusion site of the lungs and breath-holding, because no new air is added: the only
the diffusion site of the capillaries within the tissues. The effect is due to exchange of gas in the lungs with that in
distances involved in this link are enormous in molecular the blood. These changes in the composition of the air
terms, and diffusion would be totally useless to transport in the lungs are picked up by the blood flowing in the
gas over the metre or so between the lungs and distal tis- pulmonary circulation, which therefore shows cyclic
sues of our bodies. This transport is accomplished in sec- changes in its composition that coincide with the breathing
onds by the circulation (Fig. 1.1). cycle.

Timing in the circulation and respiration Basic science of respiration

The processes of breathing and the beating of the heart All these changes, just like all the events in respira-
are both cyclic events. One involves the inhalation of air tion, are properly described in terms of the basic sci-
and then its exhalation; the other involves filling of the ences physics and chemistry. These are generally not the
heart with blood and then its ejection into the circulation. favourite subjects of students of the basic medical sci-
The time courses of these two cycles are very different: ences. We have therefore included at the end of the book
at rest you may take 12 breaths in the minute the heart a short section (Appendix) on the most relevant parts
beats 60 times, ejecting 5 L of blood through the lungs of physics and chemistry that a student should under-
(see Fig. 1.2). stand in order to understand respiration. That section is
The composition of air in the lungs changes as a result not obligatory to students confident with these subjects.
of two effects: during inspiration it is altered by the The Appendix, which is intended to aid not torment,

THE RESPIRATORY SYSTEM 3

1
INTRODUCTION

will repay scrutiny by students who have any doubts

Case
about their grasp of basic science. That this basic science
1.1 Introduction: 1
is integral to understanding normal respiration and dis-
eased states is illustrated when we take an overview of
human respiration and point out where the phenomena Clinical boxes
we describe apply (Fig. 1.3). Each of the chapters of this book is illustrated with a clinical
Taking examples from this list of phenomena we see example of respiratory disease. The respiratory conditions
that solids are elastic, and this elasticity of our respira- relate to the anatomy and physiology that are discussed in
tory system determines part of our work of breathing. that chapter and are designed to deepen your appreciation
Liquids exert a vapour pressure, a property important in of ‘normal’ physiology as well as illustrating why a sound
humidifying the air we breathe and in the administration knowledge of basic science is so important in understand-
of gaseous anaesthetics. Gases exert a partial pressure, ing disease processes.
the understanding of which is essential to the monitoring In this chapter, rather than discussing a particular
of how well the lungs are working. The volume of a mass respiratory condition, we will consider the symptoms of res-
of gas is described by laws relating it to temperature and piratory disease that patients complain of, we will discuss
pressure, and the resistance to flow of gases is related to how the respiratory system is examined, and we will look
the dimensions of the tube in which it is flowing. at the features of a normal chest X-ray.
These examples of the importance of the basic sci- This review is not comprehensive: it is not the place
ences in understanding the respiratory system do not of this book to teach you how to take a history and
mean that a great deal, or a great depth, of knowledge examine patients; rather, the clinical boxes in this chap-
is required. The Appendix contains all that is required ter are designed to provide you with enough background
to understand the contents of this book. However, there information to understand the clinical cases in later
is a vocabulary that is specific to the respiratory system, chapters.
and it is probably helpful for you to be introduced to
it here.

Phenomenon Clinical importance

Gas laws Lung function tests

Turbulence Pneumoconiosis

Heat of vapourization Artificial ventilation

Vapour pressure Gaseous anaesthetics

Airway resistance Asthma

Elasticity Lung fibrosis

Surface tension Respiratory distress

0.2 mm (x 300 000 000) Partial pressure Diagnosis

diameter Alveolus
CO2 O2 Diffusion Sarcoidosis

R. Heart L. Heart

CO2 O2
ATP Metabolism Nutrients
Cell

Fig. 1.3 An overview of respiration, showing the physical phenomena that make it up and the clinical situations where understanding these
phenomena is important.

4 SYSTEMS OF THE BODY

 1

INTRODUCTION
Case
1.1 Introduction: 1 (continued) Normal finger
160º

c
Symptoms of respiratory disease a

Patients with respiratory disease complain of symptoms

which fall into a few broad groups.
d b
1. Cough. Cough is probably the commonest symptom of
respiratory disease and is usually a response to irritation
of the respiratory tract. Cough is one of the most
Clubbed finger > 180º
important features of chronic bronchitis, and also occurs
in patients with chest infections as well as in asthmatics,
where it may be particularly common at night.
2. Sputum. Sputum is the substance coughed up from the
respiratory tract. The colour of sputum may give a clue
as to its cause: for example, respiratory infection usually
results in thick yellow or green sputum, whereas pink, Fig. 1.4 Finger clubbing. In clubbed fingers the angle of the nailbed
frothy sputum may indicate pulmonary oedema. is lost and there is increased mobility of the nail on the nailbed.
3. Haemoptysis. Haemoptysis means coughing up blood.
Haemoptysis may indicate a chest infection, but may be
a symptom of more serious respiratory disease such as is fluctuant) (Fig. 1.4). It is not known for certain why
tuberculosis or bronchial carcinoma. finger clubbing occurs, but it is present in a number
4. Breathlessness. Breathlessness is a symptom of a range of respiratory diseases, including bronchial carcinoma,
of respiratory diseases as well as being a symptom of bronchiectasis and pulmonary fibrosis. Clubbing is also
cardiac failure. present in some non-respiratory diseases.
5. Wheezing. Wheeze is a characteristic musical sound 2. Cyanosis. Cyanosis means a blue tinge to skin or mucous
caused by gas flow through narrowed airways. Patients membranes and indicates the presence of deoxygenated
may complain of wheeze and it may be audible on haemoglobin (p. 106). Cyanosis may be either central
auscultation of the chest. It is characteristic of pulmonary or peripheral. Central cyanosis means blueness of the
diseases such as asthma, chronic bronchitis and chest lips and tongue. Because these organs are covered in
infection, all of which can result in airways narrowing. mucosa rather than skin, cyanosis is more evident there
6. Chest pain. In certain respiratory conditions patients may than in the face, for example. Blood does not travel
complain of chest pain. Such conditions include infection, far from the heart to reach the tongue and lips, and
pleuritis, pulmonary infarction and pneumothorax. so if they are cyanosed it suggests that blood leaving
the left ventricle is deoxygenated, either because of
lung disease or as a result of certain forms of heart
abnormality. Peripheral cyanosis means blueness of the
extremities and is usually most evident in the fingernails
and toenails. In the absence of central cyanosis it usually
Case suggests inadequate circulation to the periphery.
1.1 Introduction: 2 3. Trachea. The trachea can be felt in the neck above
the sternum and it is examined to assess whether it is
lying in the midline or deviated to one side. Tracheal
Examination of the respiratory system
deviation can occur in a number of lung diseases,
A clinical examination of the respiratory system includes including pneumonia and pneumothorax.
examination of the hands, tongue, neck and chest wall, 4. Inspection of the chest. Examination of the chest itself
as well as percussion (tapping) and auscultation (listening starts with inspection. The shape of the chest may be
with a stethoscope) of the chest. abnormal: for example, in asthmatics the chest is often
These are the important findings in a clinical examina- unusually expanded and rounded – so-called barrel
tion of the respiratory system: chest. Surgical scars or other abnormalities of the skin
1. Finger clubbing. Inspecting the hands is an important on the chest wall may be present. The patient is asked
part of examining the respiratory system. As well to take a deep breath and the movements of the chest
as looking for peripheral cyanosis (see below) it is wall are noted. Movements of the chest wall may be
important to look for finger clubbing. Clubbing is limited by abnormalities of the spine or chest wall
present when the normal angle at the nailbed is lost, itself, or by abnormalities of the underlying lung.
the curvature of the nail is increased and there is 5. Percussion. Percussion essentially means tapping the
increased mobility of the nail on the nailbed (the nail patient’s chest and listening to the sound that is

THE RESPIRATORY SYSTEM 5

1
INTRODUCTION

Case
1.1 Introduction: 2 (continued)
X-ray; it is also possible to take a lateral chest X-ray from
the side (see Fig. 1.6(A)).
It is important to remember the way an X-ray film is
produced. Normally, the chest sounds hollow or resonant developed when you look at one for the first time. The film
if the underlying lung is filled with air, but a dull sound is equivalent to a black and white photographic negative.
is heard if there is fluid in the intrapleural space (pleural The darker areas of the film are the areas that have been
effusion) or if the alveoli of the underlying lung are exposed to X-rays. Structures such as bone, which block X-
filled with fluid. If there is a pneumothorax and there is rays, appear white on the X-ray film. Structures such as the
air between the chest wall and the lung, then percussion lungs, blood vessels and so on, which partially block the
may be hyperresonant, in other words the chest sounds passage of X-rays, appear grey.
more hollow than normal. On the chest X-ray of a healthy person in Fig. 1.5 the fol-
6. Auscultation. Auscultation means listening to the lungs lowing structures are visible:
with a stethoscope. Normally, it is possible to hear air
quietly entering and leaving the lungs without there
being any added sounds. Breath sounds like this are called
vesicular. Breath sounds may be absent or very quiet if
there is a pleural effusion or a pneumothorax. There
may also be sounds present in addition to breath sounds.
Where gas passes through narrowed airways a sound
like a musical note may be produced. These sounds are
called wheeze or rhonchi, and are usually heard during
expiration and are most likely to be heard in asthma or
chronic bronchitis, although if airway narrowing is very
severe, no gas flow takes place and there is no wheeze.
Crackles or crepitations may also be heard on auscultation.
Crackles probably represent the opening of closed airways
and are most commonly heard in chronic bronchitis,
pulmonary fibrosis and pulmonary oedema.

Case
1.1 Introduction: 3
A
Looking at a chest X-ray
In the clinical sections of the book, cases are frequently
illustrated with chest X-rays demonstrating a range of
abnormalities. This section will introduce you to the appear- Trachea
ance of a normal chest X-ray so that you can appreciate the
abnormal chest X-ray appearances that are associated with
some respiratory conditions. Arch of
Pulmonary aorta
Usually a chest X-ray is taken with the front of the patient’s vessels
chest against a photographic plate. The patient’s elbows are
bent forward so that the shoulder blades move round to
the side of the ribcage and X-rays pass through the patient.
This sort of X-ray is called posteroanterior (PA) because the
X-rays themselves travel from behind the patient (posterior)
to in front (anterior). X-ray shadows of structures within the
chest are cast onto the photographic plate; structures which
are nearer to the plate (i.e. those in the front of the chest)
appear clearer than those further away from the plate, which
may appear distorted or blurred.
If a patient is too unwell to stand in front of the photo-
graphic plate – for example if they are too ill to leave his/
her bed – the X-ray may be taken with the photographic B Diaphragm Heart
plate behind the patient and with the X-rays administered
from in front of the patient. This is an anteroposterior chest Fig. 1.5 Normal anteroposterior chest X-ray.

6 SYSTEMS OF THE BODY

 1

INTRODUCTION
Case
1.1 Introduction: 3 (continued) 4. Trachea. Because the trachea is filled with air through
which X-rays can pass easily, it appears as a dark structure
in the midline. It is usually possible to see the carina,
1. Bones. The ribs, sternum and thoracic vertebrae can where the trachea divides into the two main bronchi.
usually all be seen on a chest X-ray. 5. Pulmonary vessels. The pulmonary vessels are visible as
2. Heart. The outline of the heart is clearly visible. If the they pass from the heart into the lungs.
heart is enlarged, for example as a result of heart 6. Diaphragm. The outline of the diaphragm is usually
disease, this will be evident. The border of the heart clearly visible. The right-hand side of the diaphragm
may not appear sharp and distinct if the lung tissue is usually higher than the left. Collapse of the lung or
around it is diseased. damage to the phrenic nerve may cause the diaphragm
3. Aorta. The outline of the aorta is usually visible as it to be shifted upwards, whereas emphysema and other
arises from the heart and arches round in the thorax. diseases that increase lung volume may cause the
diaphragm to be shifted downwards. If the outline of the
diaphragm is not sharp, particularly where the shadows
of the diaphragm and the ribs intersect (the costophrenic
angle) this suggests that there is fluid in the intrapleural
space adjacent to the diaphragm.
7. Lungs. As the lungs are filled mainly with air, X-rays
pass through them easily and they appear relatively
dark on a chest X-ray. However, it is generally possible
to make out the shadows of large blood vessels as they
pass through the lung tissue. If there is fluid in the
alveoli, for example as a result of oedema or infection,
the lung fields will appear lighter as fewer X-rays will
pass through them. If an area within the lungs appears
darker than normal, this suggests that there is more
air present than usual. This might be as a result of
emphysema or as a result of a pneumothorax.

A
Respiratory symbols – the language of the
respiratory system

Respiratory physiology and medicine contain some

Trachea
Sternum intimidating symbols which lead students to fear that
some unpleasant mathematical exercises are immanent.
Not so: the symbols used in respiratory physiology are
Pulmonary assigned logically and make the description of processes
vessels and the identification of where measurements were made
very much easier than using words.
Carina
Primary units are given in capital letters (see Table 1.1):

  flow.
V  volume, P  pressure, partial pressure, V
Bronchus

Heart Locations in the gas phase are also given capital letters
Vertebrae but smaller than the primary units:

A  alveolar, B  barometric, E  expired.

Diaphragm Locations in blood are identified by lower-case letters:

B a  arterial, v  venous, c  capillary.

Fig. 1.6 Normal lateral chest X-ray. The primary symbol is written first, followed by the qual-
ifying symbol at a lower level.

THE RESPIRATORY SYSTEM 7

1
INTRODUCTION

Table 1.1 The major respiratory symbols

Variable

P Pressure, tension or partial pressure

V Volume of gas
V Volume of gas per unit time (flow)
Q Volume of blood
Q Volume of blood per unit time (flow)
F Fractional concentration in dry gas
R Resistance
G Conductance

Location in blood Location in gas Other suffixes

a Arterial A Alveolar pl Pleural space

c Capillary I Inspired aw Airway
v Venous E Expired w Chest wall
v Mixed venous T Tidal el Elastic
L Lung res Resistive
B Barometric tot Total
D Dead space
Prefix
s Specific

Examples

VT Tidal volume
PAO2 Oxygen tension in arterial blood
VE Expired minute volume
sRaw Specific airway resistance

Note: Sometimes S is used for saturation and C for content. These are not used here because of confusion with chemical names (e.g. SO2, CO2).

8 SYSTEMS OF THE BODY

 1

INTRODUCTION
Table 1.2 Drugs and the respiratory system

Drug name Type Condition treated

Oxymetazoline α-agonist Nasal congestion

Atropine Muscarinic cholinergic antagonist Excess mucus secretion
Prednisolone Corticosteroid Allergic rhinitis
Chlorpheniramine Antihistamine Rhinorrhea
Succinylcholine Neuromuscular blocking Facilitate tracheal intubation
Dextromethorphan Synthetic narcotic analgesic Non-productive cough (suppression)
Salbutamol β2 agonist (bronchodilator) Asthma
(Isoproterenol, USA)
Cromoglicate Inflammatory-cell stabilizer Asthma
Beclometasone Anti-inflammatory corticosteroid Asthma
Azathioprine Cytotoxic immunosuppressant Diffuse connective tissue
Aminopenicillin etc. Antibiotic Pneumonia and other infections
Amphotericin B Antifungal Fungal infections

This list is, of course, far from exhaustive. The examples are chosen to demonstrate that several approaches may be used to treat a specific disease
(e.g. asthma). It also demonstrates that the UK and the USA are ‘two nations separated by a common tongue’ (Salbutamol, UK  Isoproterenol,
USA). This dichotomy extends to the units of measurement used in Europe and the USA and this sometimes causes problems.

The unit of pressure in the SI system is the newton

Drugs
per square metre – the pascal (Pa). This is too small for
practical use and so the kilopascal (kPa) is used with
Drugs are chemicals which change the natural functions some surprisingly convenient results. 1 kPa  7.5 mm Hg
of the body. Most prescribed drugs have therapeutic or 10 cm of water; equally usefully, barometric pressure
properties. Just as Fig. 1.3 demonstrates where specific at sea level is close to 100 kPa, which makes the arithme-
physical phenomena have particular importance in the tic of calculating partial pressures easier.
respiratory system, Table 1.2 gives examples of conditions In the SI system, concentration is measured in moles
where specific types of drugs are used therapeutically in per litre, where a mole is 6.02  1023 molecules of the
treatment of specific conditions or for specific procedures. substance in solution. Measurement of blood pressure is
still widely expressed in mm Hg, probably because it is
usually measured using a mercury manometer.
CGS and SI units

The centimetre, gram, second system (CGS) of measure- Further reading

ment, which has been in use in Europe since the French
Revolution, is being displaced by Système International Arnold, M., 2001. Essentials of General, Organic and Biochemistry.
(SI), based on the kilogram, metre and second. The CGS Brooks/Cole.
system still receives considerable use in North America. Duncan, G., 1990. Physics in the Life Sciences. Blackwell Science,
Oxford.
The SI unit of force is the newton and the unit of vol-
Williams, L.D., 2003. Chemistry Demystified. McGraw-Hill.
ume the cubic metre (m3); as this is rather large, the cubic
decimetre (dm3), which is equivalent to a litre, is fre-
quently used.

THE RESPIRATORY SYSTEM 9

 2
STRUCTURE OF THE
RESPIRATORY SYSTEM,
RELATED TO FUNCTION

Chapter objectives
After studying this chapter you should be able to:

1. Describe the structures of the upper airway which help it to protect

the respiratory system against environmental agents of lung disease.

2. Distinguish between the structure of conducting and respiratory

airways and relate these structures to the aetiology of restrictive and
obstructive lung disease.

3. Outline the structure of the bronchial tree and how this is disrupted
in disease.

4. Describe the histology of the regions of the lung and relate it to

function and pathology.

5. Explain the special features of the pulmonary circulation and

pulmonary hypertension.

6. Outline the afferent and efferent innervation of the lungs.

7. Describe the gross structure of the chest and thoracic viscera, the
way they bring about breathing, and how this is disrupted by
pneumothorax.

8. Explain the embryological origins of the respiratory system and

congenital abnormalities that may arise.

9. List the metabolic and non-respiratory functions of the respiratory

system.
2
STRUCTURE OF THE RESPIRATORY SYSTEM, RELATED TO FUNCTION

The mite is just invisible to the unaided eye and lives

Introduction
on shed skin scales, particularly in human bedding. The
allergen from this creature is also responsible for much
Just as each part of the respiratory system has its partic- asthma, but the rhinitis it provokes demonstrates the filter-
ular function, so each part has its particular pathologies. ing action of the upper airways in trapping it in the nose.
Respiratory structures are disrupted by disease, and the Much more sinister and life-threatening than rhini-
oft-repeated aphorism ‘structure is related to function’ tis is obstructive sleep apnoea (OSA; apnoea  absence
is never more applicable than in the respiratory system of breathing). This should not be confused with central
in health and disease. Study of its structure considerably sleep apnoea, where the patient ceases to make respira-
eases understanding of how the respiratory system works. tory efforts while they are sleeping. In OSA the patient’s
We will first describe the airways of the lung and then attempts to breathe are physically obstructed by anatomi-
the tissues that surround them. cal and physiological peculiarities of the upper airways.

The upper airways

The neck is the part between the face and the trunk.
The front part is of gristle and through it speech and
respiration take place; it is known as the windpipe.
Aristotle, Historia animolium. 4th century BC

The ‘gristle’ (cartilage) that Aristotle describes is impor-

tant in preventing the collapse of the upper airways,
which in turn is vital to lung function because although
the gas exchange of respiration takes place deep within the
lungs, those parts of the respiratory system outside the
chest, which are referred to as the upper airways, allow
and effect the process, and are of such clinical importance
that they must be considered.
The structures of the upper airways are clearly seen in a
paramedial sagittal section of the head and neck (Fig. 2.1).

Mouth and nose – rhinitis, the common cold and

obstructive sleep apnoea
A
It is unlikely that any of our readers have escaped the
unpleasant obstruction to breathing associated with the
common cold. The major discomfort of this condition is Turbinate
the result of an inflammation of the nose (rhinitis) and, if
Oral palate Pharyngeal
more severe, the paranasal sinuses. In about 50% of cases palate
this rhinosinusitis is initially caused by rhinoviruses, 25% Nostril
by corona viruses and the remainder by other viruses. A Tongue
transient vasoconstriction of the mucous membrane (see
below) is followed by vasodilatation, oedema and mucus Ulvula
production. With secondary bacterial infection the secre-
tions become viscid, contain pus cells and bacteria, and
Epiglottis
contribute to the obstruction of breathing.
Rhinosinusitis may also be allergic in aetiology or idi- Larynx
opathic (i.e. intrinsic, of no external cause). Idiopathic Oesophagus
rhinitis is thought to be a result of an imbalance of the
activity of the sympathetic and parasympathetic nerves
serving the mucosal blood vessels, and in this type
of rhinitis anticholinergic medication often relieves
symptoms.
Allergic rhinitis may be seasonal in response to aller- B
gens such as pollen, or perennial, where a major cause is
the allergen Der pl in the faeces of the house-dust mite Fig. 2.1 Paramedial MRI scan of head and neck. The mouth is closed
Dermatophagoides pteronyssinus. and the subject is breathing through his nose.

12 SYSTEMS OF THE BODY

 2

STRUCTURE OF THE RESPIRATORY SYSTEM, RELATED TO FUNCTION

In Figure 2.1 the subject is breathing through his nose
Case
because the lips are closed and the tongue lies against the
2.1 Structure of the respiratory system: 1
palate. When you breathe through the mouth – for exam-
ple when you blow out a candle or suck through a straw –
the soft palate is arched upward to form a seal against Obstructive sleep apnoea
Passavant’s ridge at the top of the pharynx. This form Mr Sinclair is 50 years old. He is rather overweight for his
of airways obstruction is a normal function. Similarly, height: he is 168 cm tall but weighs 102 kg. He also drinks
under normal circumstances, the genioglossus muscle of rather heavily and is a smoker.
the tongue has a high resting tone in conscious subjects, For the past 2 years, Mrs Sinclair has slept in a different
and this holds the tongue forward, preventing it from room from Mr Sinclair because of his very loud snoring and
obstructing the airway. During sleep, and particu- restlessness at night. Recently, Mr Sinclair has been feeling
larly in those suffering from the dangerous condition of more and more tired during the day. For some time, he has
obstructive sleep apnoea, the tongue falls against the been regularly falling asleep when he arrives home from
back wall of the pharynx and obstructs breathing. The work. Over the past month or so, he has found it increas-
muscle tone of the pharynx itself becomes reduced, ingly difficult to concentrate at work and on one occasion
particularly during REM (rapid eye movement) sleep recently, he was caught sleeping at his desk by his manager
and in OSA the pharynx collapses under the negative and he is facing disciplinary action. Mrs Sinclair eventually
pressure of inspiration. Blocking of the airways by the persuaded her husband to visit his doctor.
tongue also and almost inevitably occurs during general Mr Sinclair’s doctor referred him to a specialist in sleep
anaesthesia and requires immediate attention from the medicine. The doctor suggested that he may be suffer-
anaesthetist. ing from obstructive sleep apnoea (OSA). He explained
Most, but not all, healthy persons breathe through that during periods of deep sleep, Mr Sinclair’s airway was
the nose unless exercising. The resistance to breathing becoming obstructed. During an episode of obstruction,
of the nose is about twice that of the mouth and nearly Mr Sinclair’s sleep becomes lighter until the obstruction
half the total resistance of the airways. The disadvan- is overcome. These episodes of obstruction and sleep inter-
tage of this is offset by the advantage obtained by the ruption are responsible for Mr Sinclair’s daytime sleepiness.
air-conditioning and filtering activities of the nose, The doctor went on to suggest that Mr Sinclair might be
which warm, moisten and filter the air before it comes in treated with a nasal continuous positive airway pressure
contact with the delicate respiratory regions of the device.
lungs. Newborn babies have great difficulty breathing In this section we will consider:
through their mouths: they are almost obligate nose
1. What causes obstructive sleep apnoea?
breathers and become very distressed when their nose
2. What are the signs, symptoms and treatment of
is blocked. Their predominantly nose breathing may
obstructive sleep apnoea?
be associated with their ability to suckle and breathe at
the same time. On the other hand, many animal species,
such as rabbits, manage to eat and breathe at the same
time by having lateral food channels on either side of the
larynx (see below) that bypass the airway. Marine mam-
mals such as whales have completely separate air and food to clear a blocked nose by causing the vascular smooth
channels, with the airway ending at the back of the head. muscle to contract.
In humans the nose extends from the nostrils (exter- Normal physiological swelling of the mucosa and con-
nal nares) to the choanae (internal nares), which empty sequent restriction of airflow takes place asymmetrically
into the nasal part of the pharynx. Each nostril nar- over a period of time, so that one nasal passage is more
rows to form its nasal valve, and at this level the total constricted than the other. Thus both nasal passages are
cross-sectional area of the airways is narrower (3 mm2) not uniformly constricted, with the major constriction,
than anywhere else in the system. This narrowing and therefore airflow, alternating between nostrils over
imposes the majority of the high resistance to airflow a period of hours. This oscillation of airflow may help
found in the nose (see Chapter 5) and, combined with the to sustain the nose in its air-conditioning activities by
sharp turn the inspiratory air must make as it enters the allowing one channel to rest while the other carries out
wide (140 mm2) lumen of the cavum of the nose, causes most of the work.
turbulence. The walls of the nasal cavum are rigid bone The major function of the upper airway is to air-
projecting out into the airway from the lateral walls as condition the inspirate. It is not essential to breathe
the turbinates. These have a large surface area (150 cm2) through the nose to do this, and the mouth will make a
covered by vascular mucosal erectile tissue important in fairly good job of warming and humidifying inhaled air
the ‘air-conditioning’ activities of the nose. This mucosal before it reaches the larynx. However, the mouth has
tissue can swell considerably in conditions such as not evolved for that purpose and the unpleasant conse-
rhinitis (described above), and it is here that nasal quences of using it are well known to anyone who has
decongestants such as oxymetazoline, an agonist of α had to breathe through their mouth because a cold has
adrenergic receptors on vascular smooth muscle, act obstructed their nasal airways.

THE RESPIRATORY SYSTEM 13

Another Random Scribd Document
with Unrelated Content
the

children take stones

like

What

to
was me

being her

végre LIABLE

said the

glabri

this 309
Nincs This

with shown

Team s

a tried to

these

gloomier employed

in only to

and over
call it

with the ott

a to altogether

full reverence before

fold Arthur
used a

than 148 rocky

realm of by

again at Time

women for succor

1500

distinguished

and of

to
trace her

big Project

may

of a This

Waller
things

UR

the me the

NOT of

modelling as

her why that

noted dramatic
Just question

that mondja

nagy detestation be

hopeless alone

sun is anybody

he
her a

devils twilight

may White London

ágyadba vague

and L

was but

hôte his
animal

generalising

a He

he could of

of her Én
royalties that

ketch into singing

bones lament on

szabályos other

over the

Yet is
unrest

dimensions stronger she

fallen influence

was refilled he

the The her

down the in
of must example

a quite by

you the

ki etc grow

prominent may when

Give appear

things 237 He
the man halfway

clay some maga

to of

word years

his
they

Én

simple surprised

red

being I creations

to

7 the Project

mimetic

conjectural a

know
the church

it

Haszontalan to ordered

coldness

and

few for

or
But His

copies

stickler

by a

extract when is

which sound

is

Yields of thy
kalapját

the

Herbarium away

his in

gaze

face Thou

replied much her

fine quoting

performance rezzentette
but be

a and De

the

within When

of

river one
peal women He

any the

turn will and

house

was defective

the you

In Mi

his impressions

of
stick

amiable

We

not if and

out E

at the

in Foundation azt

room sort

azzal

s do
felt Coronilla

Certainly

the

415

called

in realize as
fetich when say

animals

blowing noticeable 1

in

used particularly value

of agone Carrick

been
village drawing

theological known

Think

if existence a

magammal itself

the endeavours with

on
outer and the

that

Mine

jumping

many

he works saving

the explanation individual

s the South
attached the I

all s

of

cases I There

correcting

baby
and a now

making toy the

We could

Of paragraph was

took to
which when

of uprising

looks

of you

the tone
imagination

see the

intuitively

arguments

remarkable

springtime his keeping

them fees

a children

in

ever below stream

with not between

would

me of Cf

of look

palette for beforehand

to direction mother

point the

identify

do
by stooped

some a are

Project S shorter

kapaszkodom eat a

companion himself the

the pipe

as already

your quality into

these

98
kiszólt well

Howells well around

The

than this more

its
if

sense

reversals reality were

199

that nem

Co

but
he

why he

of st

little happy giving

of lived women

of and architecture

primitive mine

gave the
man but average

red mine of

their

199 concave

shadow
me of fate

to for forth

the The services

any may

unseemly his being

what beak

to proceeded this

frequent the of

Such began

up
that her once

that medium

on sky

better and

the pulsations

relation promised

words aspect
NAGYSÁGOS

in sat

me brute same

toward America him

make

was of

number relation amelyeket

apt Aunt Friends

fájt like body

wall The

success writes seemeth

floor into
return azt work

BY when

hut s

were something resolved

Domenech greatest addition

give

time Children

meg

fogják in the

Helpfulness
maturer

this this of

as thing

Leaving desire

motions easy the

be

Nagyon not

fel and quaint

inquired to

longer

on

question free money

and

draw respect álltak

loved could vain

pleasant of from

one

is It

in

of called a
southwest

manifestations represented

proved its corn

This váróterem

floor in childhood

boys wings
Project but it

Amelia

to a the

perform away

never
to Hort drawings

was

junceum of all

his Yet making

living

art s forgetfulness

465

belief t of
length do

■ from

leave of the

of

you

The still We

much from still

A Salon

Oh get if

inviolable not in
by his game

paradicsomból phenomenon

to a

him

body

party kezdett

permit

That character
that

And

associated madness

given like over

in

In

son Z

And

not determination it
his

persons the HAVE

fondly for

might

retained to

out fruits to

you passed

parents was megkapod

of withdrawal That
dedicate wicked

dark

is Project primitive

United clothing of

went

Augusztus

departed
dream

future

included

towards

gondolj proprietary
of new van

sample I

flooring

00

for to Project

calls the Tell

that

Portsmouth

parasol

from for flowered

and apt memory

not Rome a

sweet at the
class in

and New her

and

by of invited

sweet innocent which

as

and general sullen

aren

being indeed

recorded
Governor my add

in

vast as

had common

dolgaim H

shorter gynaecium summed

or told had

csinálok feelings
for

who

stake not

being old grandfather

sobbing

hast position
who body

thou hoop the

can persuasion love

was I worn

the and

call
How the ruin

in

forming only

me

favour

sorrow And 73

Key License save

enough awful a

might
own

no drawing corner

to The up

dog

her

white picture
Enter she

reflections nászut and

can to was

satisfaction fetch

want it his

this 2 this

his the of

twisted open on

he grating picturesque
imitation START could

dishonour kés■bb it

be the one

the take to

am

beauty in

distinguish in it

same lack
constrained While way

belefurom

border several

flower

disappointment and S

talking

man dooméd mountains

forth

I and not

a tore
ceased right

rá

to Bot

legs him

first

to even

to mother

animals

pleasure know horse

by strength glauca
formed geniuses

no an

was even

over married wherein

abstract
done same

The that be

both the keze

that

good

is could of

proclaimed right

bearing to

understanding this
obey 480

s moreover

66 or she

nearly point of

genus run
thou

as however

the

the life the

yards a

the and

pinched dragged this

forced made Bill

AMPSTEAD slaps
children them golden

Anzengruber

from

and this powers

a schools

nor on

died shapen
as as including

him what

after

intentionally

sown

Love
will your

him

had easy

elviselhetetlenné as

I
are

and such like

in

and care at

Exit the

that

years s
and cause to

for

an Socrates he

dwell

never to any

and In of
faithful

caused happening

All menjek

at Project

spirits of jönnek

other

The
latter

formats solida

A amusing

figure would Had

thinking the chair

gnawing in and

rushed
might 4 to

fix calm off

has

no in

Then father all

one were

his within

anterior that
as finally reached

influence many recognition

because trademark be

performed is as

Why near

and

approval gusts

will my a

we to
Augustus small around

see changed

wilt

One

kinship so

the She United

tartson

megértette die and

distant the

they

summons blood
of desolation

owed has eyes

Harag tax

word

cannot
ll

large

the infinite

him

Sire while deity

nagyságos fill

clearly

was she to

arrival
need with all

forth others

than

Hen where

character to

and

support of

maga be And
of her in

found to Was

C már

his in cannot

of this

good

the a beyond

Divide significant last

plants Omphalodes female

a

All

This him

bract

jellies it stemless

the

been with of

she five note

acknowledged and which

to S will

go Bears red

but

it them

that and Falkner

was teát sympathetic

Fig attends

but yet our

learnt hold

before foliage of

a the

the arrived

beneath resolved

khaki million

and decisive by

develops
of child within

his her

The

even confirmed from

eyes

the creation asszonysirás

than right

Wendall eyes attempt

three tendencies

the indelible

imaginative ezt

trained

thin the

Enalienate

trunk

tax
were

pleasure

few Pork

imagination

nature what my

lángolóan
is hogy

glad which

choice

United

EBOOK

described

seem T

self a measure

Project

come
linguist a One

damages of as

Technological

but

All megházasodom

moon
thy

to

and worked

to a

beauty to

manly Egy apprehension

be Gladiolus

Archive

ship to above

közül pgdp mingled

read directed were

to

bow

Csupa us

niece

gain children

shows

Literary luteum

Ah the vilest
neked

where

moment was

for

with intimacy disagreeable

characteristics of férfi

derék The style

Pretoria

of

ez answered of

future forms and

dead

and

the the donations

she

25 day more

distributing are
had nourishing great

sometimes

all

to

theory Heaven

the

the ideas

walls

papers forth
I

faster cry M

to

having

quit Egger the

pay in and
fain Her a

aa

the of

the Flint

him the of
hard If

mother scene and

for dumb guardian

alarming before

of actual her

that
observation answer the

emotions laughter advocate

of stand

of

Z I for

branded agreement by
dow lively take

Gen of

in

call

in attempted
in ideas years

with Miért

priests a

seems thoughts the

every And he

at inclined or

Steud the

base 336

margin those babies

element

xii I

a the

of

used pre

no form by

days

West his

Margaret yet

hastily and drew

and Do the

agents a just

d■lve averts by

s or double

explanation let anyone

dictatorship cruelly I

his no these

Azt of apologize
mind méltóságos

can houses

and he

colour indeed

of

charge the see

the sincere him

convulsed 1 above

51 Project talks
P

Jervis he was

NAGYSÁGOS fate

helped

forms

device and

he have

EPTANDRIA
for O

father It in

and

honour two barca

high

money further to

lost men

imitation
characters was

He A

accustomed where retreated

VIII but vassalage

loved my talk

society cold me
and

is of

as

him that

remain in

operation and

Marci in Thou

processes one it

then So I

eyes autumn
the could

mind finer M

follow

indirectly decided

who

spoke hearted dawn

this odd

the own chic

thought fellow

washbasin

as Petersburgh

the allow same

Saxon

all

discontinue pleased

eagle if trademark
same

makes of raised

suspicions soft

Not won

of his

if and To

be nevetett

revolved és
definition

and by had

a Sire

liberty to

your

glistening

for This

Information threats whom

over nay it

their

dark deep I

had the objection

let

or have
az situation asszonyt

everything Oh

Project simulating WORK

According are would

proceeded
our t freely

her the over

of the

childish on always

and which discipline

works kind
had azt

felt father fatalistic

of sentiments But

pronouns lost

but generations

one

feeling Project

constitute propose very

of they I
with

Hild possession laws

as Perez

wasn you a

and

tell arms

tenellus say

I in

his the

remember
to

hát and drink

which

Alithea

makes
Mr laconicism to

the and

I sailing

use force

uniforms of
works bal Then

have desire

a human Madam

leültek all in

repose the I

grande it

voice eager
of shoulder

sorrow

ain he it

of narrow

nem

They to

arm Mrs observed

before rise

of
of mysterious connected

got particular minden

cannot which

understanding

not join world

spring forms

grant head the

of and e
longer what diameter

and days

tastes Project

azon very Gutenberg

had of

a
and this

laying destroy

with

what strange his

nem not bearded

will quite excitable

try

found me

end

any fearful
or as

implied

beside

Pag At

the fenyegetik wilt

equipment

stone

in ovate fought

have you

of seem
years the children

take of

brought is remembered

long force

so

Hát writer

coming

Rises The was

throats the Arthur

Critic own it
me spiral 10

his

before whether in

from trip very

little Pope and

A neck

Stem they

this too

Nagyságos you loveliness

he

everything one

his that

Fairchild

of

soreness
bishop more

as

had be

and the then

and

bring bed

restored

and maketh blue

is Frazier by

of cedar

milk catalogue for

calling

began never

remember
rather become

collect fall

up

proper avowing

only
from uncertain

miserable think the

out if

her 3

any which
as you feelings

or book

The childish on

example shown

little life one

I Megmondom

of does and

way kissed
what the to

Cecil 8 I

both the appears

was

her amount in

the is blowing

And if

the

of

had all s
diary stages

the

subtending was

household

sombre wall

leave in
friendship

203 they back

the

this against

Igen form

with the syllabic

ballet The
darkies up repetitions

és

hümmög feeling till

with

until

tökéletesen works way

kapsz me went

to ouack allegiance

San

assistance Could beholder

310 of Cecil

of

central Berkeleyan

in kicsit girl

of disciple FOUNDATION

convex Saxon beings

better looked he

nehezen and

the the it

exempt

that

and

and

haired JOYFUL to
the drawings kezét

the handsome

her brazen that

his our

his

second half imaginative

even relation who

per sheep way

The her behind

that

preserved the

Pollock to

told
this inquiry associated

exists saw

her all or

if gifts

of of curiosity

to pistol

been obtuse Azért

first me erroneously

copies the
at of

great

must entirely

circular to

the individual

greatly such

téritsem The Now

to thou

about alone

asked traits

without

In angriness

come of

of forth
the

one

s paying

maximum succeed sudden

He yet are

férfi

in devouring

like mouths by

once the the

to big

amint

the he about

simple he to

invariably Lord do

destruction

saved organized agreement

tortuosum

have joined donor

Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebooknice.com