PulmonaryAnatomyandPhysiology

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Acknowledgements

RN.comacknowledgesthevaluablecontributionsof

...NadineSalmon,MSN,BSN,IBCLCtheClinicalContentManagerforRN.com.SheisaSouthAfricantrainedRegistered
Nurse,MidwifeandInternationalBoardCertifiedLactationConsultant.NadineobtainedanMSNatGrandCanyon
University,withanemphasisonNursingLeadership.HerclinicalbackgroundisinLabor&DeliveryandPostpartum
nursing,andshehasalsoworkedinMedicalSurgicalNursingandHomeHealth.Nadinehasworkexperienceinthree
countries,includingtheUnitedStates,theUnitedKingdomandSouthAfrica.Sheworkedfortheinternationalnurse
divisionofAmericanMobileHealthcare,priortojoiningtheEducationTeamatRN.com.NadineistheLeadNurse
PlannerforRN.comandisresponsibleforallclinicalaspectsofcoursedevelopment.Sheupdatescoursecontentto
currentstandards,anddevelopsnewcoursematerialsforRN.com

KarenSiroky,RN,MSNforupdatingthecoursein2010.

LoriConstantineMSN,RN,CFNP,theoriginalauthorofthecourse.

Purpose&Objectives

Thefocusofthispulmonaryanatomyandphysiologycourseistoprovideinformationaboutthestructuresandfunctions
oftherespiratorysystem.Understandingthefundamentalstructuresandfunctionsoftherespiratorysystemwillassist
youtoprovideappropriatecareforallpatientsyouencounterandinterveneeffectivelyforthosewithalterationsin
oxygenationstatus.

Aftersuccessfulcompletionofthiscourse,youwillbeableto:

Identifythefunctionsofanatomicalstructureswithinthepulmonarysystem.

Discusstheprocessofrespirationintermsofventilation,diffusion,andtransport.

Introduction

Understandingpulmonaryanatomyandphysiologyisimportantandwillhelpyoutomanageyourpatientsoxygenation
status.Thiscoursewillreviewlowerandupperpulmonaryanatomy,bronchialcirculation,andthephysiologyofgas
exchange.Theseanatomicalstructuresworktogethertoachievetwomaingoals:deliveryofoxygentocellsandremoval
ofcarbondioxide,thewasteproductofrespiration.

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Thiscoursewillprovideyouthebackgroundknowledgeneededtoconductathoroughpulmonaryassessmentinadult
patients.Itwillprovideinformationonhowtoidentifynormalstructuralandfunctionalprocessesofthepulmonary
system.

Glossary

Alveolarventilation(Va)Istheportionoftotalventilationthatreachesthealveoliandtakespartingasexchange.

AlveoliThefunctionalgasexchangingunitsofthelungs.

AlveoliductsMicroscopicbronchioles.

BronchialTreeComprisesthebronchusandtherespectivebronchioles.

ComplianceIsameasureoftheelasticityofthelungs.

Deadspaceventilation(Vd)Isthevolumeofinspiredairthatdoesnotparticipateingasexchange.

DiaphragmIsthemajormuscleofinspiration.

DiffusionTheactualexchangeofoxygenandcarbondioxideacrosstherespiratorymembrane.

ExpiratoryReserveVolume(ERV)Thevolumeofairthatcanbeforcefullyexhaledbeyondnormaltidalvolume.

FunctionalResidualCapacity(FRC)Theamountofairremaininginthelungsattheendofquietexhalation.

HypoxiaLowamountsofoxygenatthecellularlevel.

InspiratoryCapacity(IR)Themaximumvolumeofairthatcanbeinspiredaftertheendofnormal,quietinhalation.

InspiratoryReserveVolume(IRV)Thevolumeofairinhaledduringmaximuminspirationbeyondnormaltidalvolume.

LarynxIsthevoiceboxandliesjustattheupperendofthetracheaandthelowerendofthelaryngopharynx.

MinuteVentilation(VE)Totalexpiredvolumeofairafteroneminute(equalstheVTtimesrespiratoryrate).

NasalTurbinatesAlong,narrowandcurledboneshelfwhichprotrudesintothebreathingpassageofthenose.

OxyhemoglobinDissociationCurveRepresentstherelationshipbetweenarterialoxygensaturation(SaO2)and
dissolvedoxygenintheblood(PaO2).

PharynxStartsattheinternalnaresandextendstothecricoidcartilage,andissubdividedintothenasopharynx,
oropharynx,andlaryngopharynx.

PleuraAtwolayeredprotectivemembranewhichsurroundsthelungs.

ResidualVolume(RV)Theamountofairleftinthelungsafteraforcedexpiration.

RespiratoryMembraneThebarrierbetweentheincomingairandtheblood.

SurfactantAsubstancethatisresponsibleforkeepingthealveoliopenduringexhalation,sotheydonotcollapse
completely.

TidalVolume(VT)Thenormalvolumeofairinhaledorexhaledwitheachbreath.

TotallungventilationIsthesumofthealveolaranddeadspaceventilation.

TracheaAlsoknownaswindpipe,andextendsfromthelarynxtotheprimarybronchi.

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TransportReferstothecarryingofoxygenandcarbondioxidethroughoutthecirculatorysystem.

VentilationTheexchangeofairbetweentheatmosphereandthealveoli.

VitalCapacity(VC)Themaximumamountofairthatcanbeexhaledaftermaximalinspiration.

PulmonaryAnatomy

UpperRespiratoryStructures

Theupperrespiratorystructuresincludethenoseandpharynx.Thespaceinsidethenoseknownasthenasalcavityis
dividedintorightandleftsidesbythenasalseptum,abony,cartilaginousnostrils(Tortora&Derrickson,2014).

Whenairfirstentersthenose,itisfiltered,warmed,andhumidifiedbythenasalturbinatesintheinternalnares.The
turbinatesarebony,curvedstructureslocatedwithinthenose.

Thepharynxstartsattheinternalnaresandextendstothecricoidcartilage.Thepharynxisusuallysubdividedintothe
nasopharynx,oropharynx,andlaryngopharynx.Thenasopharynxhumidifiesandfilterstheairwebreathe.Additionally,
ithelpsequalizeearpressureandmaintainsbalancebyexchangingairwithoureustachiantubes.Theoropharynxand
laryngopharynxhavebothdigestiveandrespiratoryfunctions(Tortora&Derrickson,2014).Ourolfactoryreceptorsare
alsolocatedwithinthenoseandareresponsibleforoursenseofsmell.

PulmonaryAnatomy

LowerRespiratoryStructures

Thelowerrespiratorystructuresincludethelarynx,trachea,bronchi,andlungs.Thelarynxliesjustattheupperendof
thetracheaandthelowerendofthelaryngopharynx.Thelarynx,orvoicebox,ismadeofninecartilages.Threeofthe
largestcartilagesofthelarynxarethe:

Thyroidcartilage,whichlaypersonsmayrefertoastheAdamsapple

Epiglottis,whichpreventsfoodandliquidfromenteringthetrachea

Cricoidcartilage

(Thibodeau&Patton,2009)

Thetrachea,orwindpipe,extendsfromthelarynxtotheprimarybronchi(Thibodeau&Patton,2009).

PulmonaryAnatomy

LowerRespiratoryStructures

Thetracheaisthefirstinaseriesoftubesthatfurnishairtothelungs.

Atthelowerendofthetrachea,therearetwoprimarybronchi.Therightisslightlylargerthantheleft.Thesebronchi
entertheircorrespondinglung,wheretheybranchintosecondaryandthentertiarybronchi.Thetertiarybronchibranch
intoevensmallerairways,thebronchioleorbronchialtreebecausetheprimarybronchiandtheirrespectivebranches
resembleanupsidedowntree.

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Thebronchiolecontinuetodivideintosmallerandsmallertubescalledthealveolarductsandeventuallybecome
microscopic.Eachductendsatintwoorthreealveolarsacs,whichthendivideintoseveralalveoli.Itisatthealveolar
levelthatdiffusionofgasesoccurs(Thibodeau&Patton,2009).

PulmonaryAnatomy

LowerRespiratoryStructures

Thealveoliaretrulythefunctionalgasexchangingunitsofthelungs.Thereareapproximately300millionalveoliinthe
lungs.Thisisequivalenttoover900squarefeetifopenedupandlaidoutflat(Thibodeau&Patton,2009).

Thewallsofthealveoliareextremelythinandlierightnexttoabedofcapillaries.Thisbarrierbetweentheincomingair
andthebloodisknownastherespiratorymembrane.Oxygentravelsacrossthismembraneintothebloodstreamand
carbondioxidetravelsfromthebloodstreamacrossthemembraneandintothealveoli,whereitisexhaled.

Withinthealveoliisasubstanceknownassurfactant.Surfactantisanimportantcomponentthatisresponsiblefor
keepingthealveoliopenduringexhalation.Surfactantreducesthesurfacetensionofthealveoli,keepingthealveoli
openonexhalationandincreasingtheabiltyofoxygenandcarbondioxidetocrosstherespiratorymembrane
(Thibodeau&Patton,2009;TortoraandDerrickson,2014).

TheLungs

Thelungsextendfromthediaphragm(base)toslightlyabovetheclavicles(apex)andexpandthroughtheentirerib
cage.Therightlunghasthreelobesandisresponsibleforabout55%oflungactivity.Theleftlunghastwolobesandis
responsibleforabout45%oflungactivity.

Thelungsperformtwomainfunctions:ventilationanddiffusion.Ventilationisthefunctionofboththeupperandlower
airways.Diffusionisthefunctionofthealveoliandthecapillarybedsurroundingthem.

TestYourself

AdamsAppleisanothertermusedtodescribe:

Theepiglottis

Thecricoidscartilage

ThethyroidcartilageCorrect!

Thenotchintheleftlung

ThePleura

Thepleuraisatwolayeredprotectivemembranewhichsurroundsthelungs.Theouterlayer,theparietalpleuralines
thethoraciccavityandtheinnerlayer,thevisceralpleuralinesthelungs.Thespaceinbetweenthetwopleuraisknown
asthepleuralspace.Thisspacecontainsathinlayeroflubricatingfluidthatallowsthelungstoexpandsmoothlyand
fully.

TheDiaphragm

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Anotherstructurewithinthethoraciccageisthediaphragm.Thediaphragmisalarge,domeshapedmusclelocatedat
thebaseofthelungs.Thediaphragmwillcontracttoforceairintothelungsandthenitrelaxes.Thisisnormallyan
involuntaryactionbutitcanalsobeacontrolled,voluntarilyaction.Asamajormuscleforinspirationthediaphragmis
responsibleforabout70%ofthetidalvolume.

Mostofthetimeothermusclesofrespirationarenotusedforgasexchange.Whenyourpatientneedsmorethan
normallungvolumesorhasarespiratorydiseaseprocess,thesemuscles,theexternalandinternalintercostalmuscles,
abdominals,andaccessorymusclesintheneck,mayassistinventilation(Sherwood,2012).

Pulmonary&BronchialCirculation

Thelungsreceivetheirbloodsupplyviathepulmonaryarteriesfromtheheartandthebronchialarteriesthataredirect
branchesoffoftheaorta(Tortora,2012;Tortora&Derrickson,2014).Thepulmonaryarterybringsdeoxygenatedblood
tothelungs.Thisbloodcontainshighamountsofcarbondioxide.Thebloodflowsintothecapillarysystemthatis
adjacenttothealveoli.Diffusioncausesoxygen(O2)tomovefromthelungsintotheblood,andcarbondioxide(Co2)to
movefromthebloodtothelungsforelimination.Theoxygenatedbloodexitsthelungsviathepulmonaryveinsthat
terminateintheleftatrium.Theoxygenatedbloodmovestotheleftatriumandintothegeneralcirculationofthebody,
forusebytissuesaroundthebody.

Pulmonary&BronchialCirculation

Thebronchialarteriessupplyoxygenatedbloodtothelungtissueitself,similartoanyotherarterialsysteminthebody.
Theysupplythisoxygenatedbloodtothebronchi,connectivetissueofthelungs,andthelungsthemselves.
Interestingly,deoxygenatedbloodisremovedviaeitherthebronchialveinsorthepulmonaryveins.

Asmentionedpreviously,thepulmonaryveinsgenerallybringoxygenatedbloodtotherestofthecirculation.Butthisis
mixedwithsomedeoxygenatedbloodfromthebronchialcirculation.

Thepulmonarycirculationisuniqueinthatoxygenatedbloodiscarriedbyveins,asopposedtoarteries!

TestYourself

Thepulmonaryarteriescarryoxygenatedblood.

True

FalseCorrect!

PulmonaryPhysiology

Athoroughunderstandingoftheanatomyofthepulmonarysystemisnecessarytounderstandtheroleandfunctionof
therespiratorysystem,whichistheventilation,diffusion,andtransportofgasesprimarilyoxygen(O2)andcarbon
dioxide(Co2).

PulmonaryPhysiology

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Ventilation:Theactualexchangeofairbetweentheatmosphereandthealveoli.Literally,ventilationistheprocessof
breathingoxygenatedairintoyourlungsandexhalingcarbondioxide.

Diffusion:Theactualexchangeofoxygenandcarbondioxideacrosstherespiratorymembrane.Diffusionoccurswhen
theoxygenmoleculesmovefromthealveoliintothebloodstreamandthecarbondioxidemoleculesmovefromthe
bloodstreamintothealveoli.

Transport:Oftenforgotten,transportreferstothecarryingofoxygenandcarbondioxidethroughoutthecirculatory
system.Thisrequiresthehearttopumptheoxygenatedbloodoutviatheaorta,arteriesandarterioles.The
deoxygenatedbloodisthenreturnedtotheheartviathevenules,veins,andthesuperiorandinferiorvenacava.

Ventilation:Abbreviations

O2Oxygen

PO2Partialpressureofoxygen

PaO2Partialpressureofarterialoxygen

CO2CarbonDioxide

PaCO2Partialpressureofarterialcarbondioxide

SaO2Oxygensaturationofarterialblood

pHMeasureofacidityoralkalinity

VAAlveolarventilation

VDDeadspace

SpO2Pulseoximetryoxygenation

BreathSounds

Breathsoundsareproducedbyturbulentairflow.Ingeneral,thelargertheairway,thelouderandmorehighpitched
thebreathsoundwillbe.

Normalbreathsoundsinclude:

Vesicularbreathsounds:Lowpitched,softsoundsusuallyheardovermostlungfields.Soundsliketherustlingof
windintrees.
Bronchial(tracheal)breathsounds:Highpitched,harshandloudsoundsheardoverthetracheaandlarynx.
Soundshollowandtubular.
Bronchovesicularbreathsounds:Moderate,mixedqualitysoundsheardoverthemajorbronchiwherefewer
alveoliarelocated.

Abnormalbreathsoundsareextrasoundsthatarereferredtoasadventitiousbreathsounds.

(Jarvis,2012)

VentilationNormalLungMechanics

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Normally,whenthediaphragmcontracts,itmovesdownward,increasingthediameterofthechestandelevatingthe
lowerribs.Thisactiondecreasestheamountofnegativepressurewithinthepleuralspaceanddecreasestheamountof
negativepressurewithinthealveoli.Thischangeinpressureresultsinairbeingpulledintothelungs.Whenthelungs
arefilledwithair,thepressureswithinthelungsaregreaterthanthepressureintheatmosphere,andairisexhaled
(Sherwood,2012).Anyconditionthataltersnormallungmechanicswillaltertheventilationcapabilityofthelungs.

Examplesinclude:

COPD
Emphysema
Pneumonia
Flailchest
Hemoorpneumothorax
GuillianBarresyndrome
Spinalcordinjury

MajorFunctionsoftheRespiratorySystem

Therearefourmainfunctionsoftherespiratorysystem:

1. Supplyingoxygentothebody.
2. Removingwaste(carbobdioxide)frombodytissues
3. Maintaininghemostasis(acidbasebalance)ofarterialblood
4. Maintaingheatexchange

(Jarvis2012)

Bysupplyingoxygentothebodyandeliminatingcarbondioxidefromthebody,respirationmaintainstheacidbase
balanceofthebody.WhenthisbalancemovesoutofanacceptablepHrange,thelungscancompensatetotryto
restorethepHbalance.Hypoventilation(slow,shallowbreathing)canincreasecarbondioxidelevelsinthebloodby
removinglesscarbondioxidethanusual.Conversely,hyperventilation(rapid,deepbreathing)cancauseashiftinblood
pHlevelsbycausingmorecarbondioxidetobeeliminated(Jarvis,2012).

Forareviewofrespiratoryversusmetabolicacidosis/alkalosispleasereviewRN.comscourse:InterpretingABGs:The
Basics.

PhysiologyofVentilation

Anydiseaseprocessorinjurythatimpactsthelungscouldimpactoneoftheaboveelementsofventilation.The
physiologyforthelungsissuchthatcompensatorymechanisms(e.g.breathingmorerapidlyormoredeeply)mayoccur
spontaneouslyordeliberately.

Asmentionedpreviously,muchofventilationoccursspontaneously,throughchemoreceptorsandstretchreceptorsthat
sendandreceiveinformationfromthebrain.

RespiratoryReceptors

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ChemoreceptorsreacttothepHofthecerebralspinalfluid(whichisimpactedbythepHoftheblood)andactsuponthe
respiratorycenterinthebraintocorrecttheimbalance.IfthepHislow(acidosis),thechemoreceptorsstimulatethe
respiratorycentertoincreasetherespiratoryrate,inanefforttonormalizethebloodpH.Conversely,ifthepHishigh
(alkalosis),thechemoreceptorswillstimulatetherespiratorycentertodecreasetherespiratoryrate.

PeripheralreceptorsintheaortaandcarotidbodiesalsorespondtochangesinpHoftheblood,andstimulatethe
respiratorycenter.

Thestretchreceptorsofthebronchiandbronchiolesreacttothephysicalstretchingofthelungsandtellthebrainwhen
inflationofthelungsshouldbestopped.Thisinformationisconductedtothepneumotaxicpartofthepons.This
stimulationoftheponsinhibitstherespiratorycenterandpreventsthelungsfromoverinflatingandbeginstheprocess
ofexhalation.

LungVolumeTerminology

Thefollowingtermssummarizeslungvolumesandcapacities.Deviationsfromthesenormalvaluesusuallyresultina
deviationinthelungsabilitytoventilate(Sherwood,2012).

TidalVolume(VT)Thenormalvolumeofairinhaledorexhaledwitheachbreath.About500mlisthenormalvalueina
healthyyoungmale.Comparativevalue=about2cups.

InspiratoryReserveVolume(IRV)Thevolumeofairinhaledduringmaximuminspirationbeyondnormaltidalvolume.
About3,000mlisthenormalvalueinahealthyyoungmale.Comparativevalue=1and2literbottlesofsoda.

InspiratoryCapacity(IR)Themaximumvolumeofairthatcanbeinspiredaftertheendofnormalquietinhalation.
About3,500mlisthenormalvalueinahealthyyoungmale.Comparativevalue=Justunder1gallon.

ExpiratoryReserveVolume(ERV)Thevolumeofairthatcanbeforcefullyexhaledbeyondnormaltidalvolume.About
1,000mlisthenormalvalueinahealthyyoungmale.Comparativevalue=Approximately1quart.

ResidualVolume(RV)Theamountofairleftinthelungsafteraforcedexhalation.About1,200mlisthenormalvalue
inahealthyyoungmale

FunctionalResidualCapacity(FRC)Theamountofairremaininginthelungsattheendofquietexhalation.About2,200
mlisthenormalvalueinahealthyyoungmale.Comparativevalue=Abitmorethana2Literbottleofsoda.

TotalLungCapacity(TLC)Thetotalvolumeofairintheupperandlowerconductingairwaysandalveoliattheendof
maximuminspiration.About5,700mlisthenormalvalueinahealthyyoungmale.

Themaximumamountofairthatcanbeexhaledaftermaximalinspiration.About4,500mlisthenormalvalueina
healthyyoungmale.Comparativevalue=Aboutthesameas6bottlesofwine.

MinuteVentilation(VE)Totalexpiredvolumeofairafteroneminute(ThisequalstheVTtimesrespiratoryrate).About
6,000mlisthenormalvalueinahealthyyoungmale.

Diffusion

Diffusionisthesecondstepintheprocessofrespiration.Diffusionreferstotheexchangeofcarbondioxideandoxygen
acrosstherespiratorymembrane.Diffusionoccursdownaconcentrationgradientfromanareaofhighertoanareaof
lowerconcentration.

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Duringinspiration,theoxygeninthelungsisathighconcentration.Itmovesacrosstherespiratorymembraneinthe
pulmonaryarterioleswheretheoxygenconcentrationisratherlow.Atthesametimethehighconcentrationofcarbon
dioxidemovesoutofthebloodandintothelungs.

Thenewlyoxygenatedbloodispumpedtotheleftsideoftheheartandintothegeneralcirculation.Theairinthelungs,
nowfilledwithcarbondioxide,isexhaled,andtheprocessbeginsagain.

TestYourself:

Diffusionisthemovementofmoleculesfromahightoalowconcentration.

TrueCorrect!

False

Transportation

Thetransportofoxygenandcarbondioxidetothecellsisthefinalstepinrespiration.Oxygenistransportedintheblood
intwoways:boundtohemoglobinontheredbloodcellanddissolvedintheplasma.Hemoglobinbindstodissolved
oxygenintheblood,untilthemoleculeisfullysaturated,andcanbemeasuredbypulseoximetryastheSpO2.

Theremainingoxygenisdissolvedintheplasmaandcanbemeasuredbyarterialbloodgassampling(PaO2).Thenormal
SpO2isabove95%.AnormalPaO2(partialpressureofarterialoxygen)is80100mmHg(mercury).

OxyhemoglobinDissociationCurve

Theoxyhemoglobindissociationcurveisafundamentalconceptinunderstandinghowoxygenationoccurs.Asthe
amountofoxygenintheatmosphere(ortothepatientthroughsupplyingexternaloxygen)increasesthePaO2will
increasebutonlyuptoacertainpoint.Generallyatabout60%oxygen,thecurveflattensoutandthereisrelatively
littlechangeintheoxygensaturation.

Also,thepredictabilityofthecurvereliesonthepatientbeingnormothermic,andthepHbeingwithinthenormalrange.
Wheneitherofthesefactorsisimpacted,theoxyhemoglobindissociationcurveisimpactedandanincreaseinoxygen
willnotaffecttheoxygenationofthebloodinthesamefashion.

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EliminationofCarbonDioxide

Thesecondkeypartoftransportistheeliminationofcarbondioxide,theproductofcellularwaste.Itistransportedin
thebloodinthreeways:

ItcanbedissolvedintheplasmaandisreflectedinthearterialbloodgasasthePaCO2(normalvaluesare3545
mmHg).
Itcanbecombinedwiththehemoglobinmolecule.
Itiscarriedintheformofbicarbonate.InnormalrespirationCo2eventuallyreachesthealveolarcapillarybed
whereitisreleasedfromthehemoglobinmolecule,diffusedacrosstherespiratorymembraneintothealveoli,
andfinallyexhaled.

EliminationofCarbonDioxide

Althoughwenormallythinkofthelungsasbeingcriticalinoxygenatingthecellsofthebody,theeliminationofcarbon
dioxideiscriticaltothepH,ameasureofhowacidorhowalkalinethebloodis.

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ThenormalpHofthebloodis7.357.45.WhenthepHisnormal,alongwithnormaloxygenlevels,therespiratory
systemisfunctioningatitsnormal,basecapacity,keepingourtissueswelloxygenatedandremovingthewasteproducts
ofthecellsadequately.

Conclusion

Athoroughknowledgeofpulmonaryanatomyandphysiologyisessentialtohealthcareproviderstoeffectivelyevaluate
andcareforpatients.

Althoughthepulmonarysystemanditsphysiologicalprocessescanbecomplex,theyclearlyimpactotherpartsofthe
body,andarecriticaltothefunctionofallbodyparts.

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References

Jarvis,C.(2012).PhysicalExamination&HealthAssessment(6thed.).StLouis,Missouri:ElsevierSunders.

Sherwood,L.(2012).Humanphysiology:Fromcellstosystems(8thed.)Belmont,CA:CengageLearning;Wadsworth
Publishing.

Thibodeau,G.,&Patton,K.(2009).Anatomy&Physiology(7thed.)St.Louis:Mosby.

Tortora,G.,&Nielson,J.(2012).Principlesofhumananatomy(12thed.).Hoboken,NJ:JohnWiley&Sons.

Tortora,G.,&Derrickson,B.(2014).Principlesofanatomyandphysiology(14thed.).Hoboken,NJ:JohnWiley&Sons.
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