Learning Objectives
1. Anatomy of the lungs
- connected to trachea by right & left bronchi
- inferior surface: diaphragm
- enclosed by pleurae attached to the mediastinum
- cardiac notch — indentation on surface of left lung
- lobes separated by fissures
- bronchopulmonary segment — division of a lobe
- pulmonary lobule — subdivision formed as bronchi
branch into bronchioles
- interlobular septum — wall composed of connective
tissue; separates lobules from one another
- blood supply
• pulmonary artery — arises from the pulmonary
trunk; carries deoxygenated arterial blood to alveoli
then becomes pulmonary capillary network
• pulmonary capillary network consists of tiny
vessels with very thin walls that lack smooth
muscle fibers
• capillaries branch & follow bronchioles & structure
of alveoli
• respiratory membrane — capillary wall meets
alveolar wall
• oxygenated blood drains from alveoli by pulmonary
veins which exit the lungs through hilum
- nervous innervation
• parasympathetic — bronchoconstriction
• sympathetic — bronchodilation
• autonomic nervous system control: reflexes like
coughing and ability of lungs to regulate oxygen &
carbon dioxide levels
• sensory nerve fibers arise from vagus nerve (n. X)
• pulmonary plexus — region on lung root formed by
entrance of nerves at hilum which then follow
bronchi & branch to innervate muscle fibers, glands
and blood vessels
- pleura of the lungs
• visceral pleura — superficial to the lungs, extends
into & lines lung fissure
• parietal pleura — outer layer that connects to
thoracic wall, mediastinum, diaphragm
• visceral & parietal pleura connect at hilum
• pleural cavity — space between the 2 layers
• functions of the pleura:
‣ produce pleural fluid — secreted by mesothelial
cells & acts to lubricate surfaces (reduces
friction to prevent trauma during breathing,
creates surface tension that helps maintain
position of lungs against thoracic wall)
‣ create cavities separating major organs —
prevents interference due to movement of
organs, preventing spread of infection
2. Physiology of breathing
- inspiration & expiration are dependent on differences
in pressure between atmosphere & lungs
- Boyle’s law — in gas pressure increases as volume
decreases
- pulmonary surfactant secreted by type II alveolar cells
mixes with water and helps reduce surface tension of
alveoli during expiration
- pulmonary ventilation is driven by pressure
differences; air flows down pressure gradient
• inspiration is the process of air entering the lungs
‣ diaphragm contracts, moves inferiorly toward
abdominal cavity creating larger thoracic cavity
& space for the lungs
‣ contraction of external intercostal muscles
moves ribs upward & outward causing ribs cage
to expand, increases volume of thoracic cavity
 ‣ due to adhesive force of pleural fluid, expansion
of thoracic cavity forces lungs to stretch &
expand
‣ increase in volume leads to decrease in intra-
alveolar pressure (pressure becomes lower than
atmospheric pressure)
‣ pressure gradient drives air into lungs
• expiration is the process of air leaving the lungs
‣ elasticity of lung tissue causes lung to recoil as
diaphragm & intercostal muscles relax
‣ intrapulmonary pressure rises above atmospheric
pressure; pressure gradient causes air to leave
lungs
- respiratory volume: volumes of air moved by or
associated with lungs at given point in respiratory
cycle
• tidal (TV) — amount of air that enters lungs during
quiet breathing 500 ml
• expiratory reserve (ERV) — amount of air you can
forcefully exhale past normal tidal expiration up to
1200 ml for men
• inspiratory reserve (IRV) — produced by deep
inhalation past tidal inspiration
• residual (RV) — air left in lungs if you exhale as
much air as possible; prevents alveoli from
collapsing
- gas exchange:
• gas exchange involves simple passive diffusion of
oxygen & carbon dioxide down partial pressure
gradients; no active transport
• partial pressure gradient — difference in partial
pressure between capillary blood & surrounding
structures (alveolar air & pulmonary capillary
blood)
• rate of gas exchange id directly proportional to
surface area across which exchange takes place —
during exercise surface area can be increased to
enhance rate of gas transfer
3. All about pneumothorax
- abnormal collection of air in pleural cavity
- air enters through damage to chest wall/lung/gas-
producing microorganisms
• positive pressure in pleural space if air enters —
lung partial/complete collapse
- types of pneumothorax
• primary pneumothorax — no clear cause;
secondary to ruptured blebs (small sacs of air on
lung surface)
• secondary pneumothorax — occurs with existing
lung disease
• tension pneumothorax — one-way valve formed by
damaged tissue (air enters then cannot escape)
causing build up of intrathoracic pressure that
results in impaired cardiac and respiratory function
• traumatic pneumothorax — follows physical
trauma to chest or may be result of medical
procedure
- signs & symptoms:
• sharp chest pain (one-sided)
• dyspnea
• tachycardia
• cyanosis
• hypercapnia — confusion, coma
• diminished/absence of breath sounds on affected
side
• hyper-resonance to percussion
• decreased vocal tactile fremitus
• trachea displace away from affected side
• tension pneumothorax may cause
‣ decreased BP & oxygen saturation
‣ epigastric pain
‣ displaced apex beat
‣ distended neck vein
- treatment:
• pleurodesis/pleurectomy — repeated pleurectomy
• tension pneumothorax — needle chest
decompression
4. Hemothorax
- presence of blood in pleural space, source may be
from chest wall, lung parenchyma, heart, great vessels
- may result from extrapleural (traumatic disruption of
chest wall tissues with violation of pleural membrane
— sources of bleeding are intercostal & internal
mammary arteries) or intrapleural injury (blunt or
penetrating injury, hemorrhage may result from injury
to major arterial or venous structures within thorax or
heart itself)
- response: hemodynamic or respiratory
• loss of 750—1500 mL may cause early symptoms
of shock (tachycardia, tachypnea, decreased PP)
• large enough collection of blood causes patient to
experience dyspnea & may produce clinical finding
of tachypnea
- physiologic resolution: within several hours of - commands the contraction & relaxation of respiratory
cessation of bleeding lysis of existing clots by pleural muscles by sending impulses to cell bodies of motor
enzyme begins neurons supplying these muscles
- lysis of RBCs marked by increased protein - consists of 2 neural clusters:
concentration of pleural fluid & increase in osmotic • dorsal respiratory group (DRG)
pressure within pleural cavity ‣ consists mostly of inspiratory neurons that
- elevated osmotic pressure favors transudation of fluid supply inspiratory muscles
into pleural space (can progress into symptomatic ‣ passive expiration occurs when firing rate ceases
bloody pleural effusion) and inspiratory muscles relax
- late physiologic sequel of unresolved hemothorax: ‣ has important interconnections with ventral
• empyema — bacterial contamination of retained respiratory group
hemothorax, can lead to bacteremia & septic shock • ventral respiratory group (VRG)
• fibrothorax — fibrin deposition develops in ‣ composed of inspiratory & expiratory neurons
organized hemothorax & coats both pleural both which remains inactive during normal quite
surfaces; traps lung in position preventing from breathing
expanding fully resulting in persistent atelectasis ‣ overdrive mechanism when demands for
(partial collapse or incomplete inflation) & reduced ventilation are increased
pulmonary function ‣ important in active expiration — stimulates
expiratory muscles (abdominal & internal
5. Pleural effusion
intercostal muscles)
- collection of fluid abnormally present in pleural space
• DRG doesn’t generate basic rhythm of ventilation,
usually resulting from excess fluid production or
it is generated in the pre-Botzinger complex —
decreased lymphatic absorption
- natural balance of the pleural space: region in upper end of VRG that display pacemaker
• hydrostatic & oncotic forces in visceral & parietal activity
pneumothoraxic center
pleural capillaries
• located in the pons
• persistent sulcal lymphatic drainage
• exert fine-tuning influences over medullary center
- pleural effusion may result from disruption of this
to help produce normal, smooth inspirations &
natural balance
expirations
- some mechanisms that may play a role in formation of
• sends impulses to DRG that help switch off
pleural effusion:
• altered permeability of pleural membranes inspiratory neurons, limiting duration of inspiration
• dominates over apneustic
• reduction in intravascular oncotic pressure
• without pneumothoraxic brakes, breathing pattern
• increased capillary permeability
• reduction of pressure in pleural space consists of prolonged inspiratory gasps abruptly
interrupted by brief expirations (apneusis)
• etc
apneustic center
- net result: flattening or inversion of diaphragm,
• prevents inspiratory neurons from being switched
mechanical dissociation of visceral & parietal pleura,
off
restrictive ventilatory defect
• provides extra boost to inspiratory drive
- generally classified as:
• promotes apneusis
• transudates — result from imbalance of oncotic &
hydrostatic pressures (effusions are usually ultra
filtrates of plasma)
• exudates — result from inflammatory processes of
pleura or decreased lymphatic drainage
- treatments:
• thoracentesis — removing fluid with catheter
• tube thoracostomy
• pleurodesis — instilling an irritant into pleural
space to cause inflammatory changes resulting in
bridging fibrosis in pleural space obliterating
potential pleural space
• indwelling tunneled pleural catheters

6. Respiratory center
medullary respiratory center (primary)
7. D & E in ABCDE
- Disability
• alert
• voice responsive
• pain responsive
• unresponsive
- Exposure
8. Oxygen mask vs nasal cannula
- nasal cannula
• delivery of oxygen concentration between 24 to
40% at flow rate between 1 to 6 L/minute
- face mask
• allows higher concentrations & rates of flow of
oxygen
• deliver oxygen concentration from 40 to 60% at
flow rates between 10 to 12 L/minute
9. Acute shortness of breath
- dyspnea is the medical term for breathlessness or
shortness of breath
- usual causes: left ventricular failure, pulmonary
thromboembolism, pneumonia, spontaneous
pneumothorax
- less common causes: massive collapse of one lung due
to inability to clear airways of thick, tenacious
secretions or first attack of asthma
10. Causes of tracheal deviation (2 types)
- results from unequal intrathoracic pressure within
chest cavity
- mediastinum will shift towards site with relatively
higher negative pressure compared to opposite side
• deviation towards diseased side
‣ atelectasis
‣ agenesis of lung
‣ pneumonectomy
‣ pleural fibrosis
• deviation away from diseased side
‣ pneumothorax
‣ pleural effusion
‣ large mass
Weekly Objectives
1. Embryological development of the lung and
diaphragm
2. Structure anatomy of the lung, pleura, relational
between chest wall, thorax and mediastinum,
lungs and their lobes, vascular system of thorax,
vagus and phrenic nerves, structure of
diaphragm, lymphatic system of the lung
3. Pressure differences in chest wall, diaphragm,
pleura and airways
4. Two main disorders in the lung
5. Classify type and management of pneumothorax
6. Function of chest tube
7. Lung oedema