AIRWAYS

The airways, forming the connection between the

outside world and the terminal respiratory units, are of
central importance to our understanding of lung function
in health and disease. Intrapulmonary airways are
divided into three major groups: bronchi (Fig. 1-7), membranous
bronchioles (Fig. 1-8) and respiratory bronchioles/
gas exchange ducts (Fig. 1-9). Bronchi, by definition,
have cartilage in their wall. Respiratory bronchioles
serve a dual function as airways and as part of the alveolar
volume (gas exchange).
The anatomic dead space, as measured by the singlebreath
nitrogen dilution technique, measures principally
the volume of the extrapulmonary (upper) airways (see
Chapter 43) and the intrapulmonary bronchi.27 The
trachea and bronchi are cartilaginous. The membranous
bronchioles (noncartilaginous airways of ~1 mm diameter
or less), although exceedingly numerous, are short.
They consist of about five branching generations and end
at the terminal bronchioles. In contrast to the bronchi,
the membranous bronchioles are tightly embedded in

the connective tissue framework of the lung and therefore

enlarge passively as lung volume increases.28 Histologically,
the bronchioles down to and including the
terminal bronchioles ought to contribute about 25% to
the anatomic dead space. In life, however, they contribute
little because of gas phase diffusion and mechanical
mixing in the distal airways resulting from the cardiac
impulse. By definition, the respiratory bronchioles and
alveolar ducts do not contribute to the anatomic dead
space. The volume of the respiratory bronchiole-alveolar
duct system is approximately one third of the total alveolar
volume, and it is into this space that the fresh air
ventilation enters during inspiration.
Most airway resistance resides in the upper airways
and bronchi. Normally, smooth muscle tone in the large
airways maintains partial constriction. Minimal airway
diameter in the human lung, about 0.5 mm, is reached

at the level of the terminal bronchioles; succeeding generations

of exchange ducts (respiratory bronchioles and
alveolar ducts) are of constant diameter (see Fig. 1-9).29,30
The functional significance of centralized resistance is
that the terminal respiratory units (the functional alveoli)
within a lung subsegment are ventilated chiefly in proportion
to their individual distensibilities (compliances)
because most of their airway resistance is common. This
is demonstrated normally by the finding that regional
lung ventilation is dependent upon the initial volumes
of the alveoli. Terminal respiratory units toward the top
of the lung, which are more expanded at FRC, do not
receive as great a share of the inspirate as do the terminal
respiratory units near the bottom of the lung.
The balance between anatomic dead space volume,
which ought to be as small as possible for efficient alveolar
ventilation (dead space–to–tidal volume ratio), and
airflow resistance, which means the airway diameter
ought to be as large as possible for low work of breathing,
requires a compromise. Normally, anatomic dead
space is not maximal, nor is resistance minimal.