Cor Pulmonale Anatomy

To better understand cor pulmonale, it helps to understand the anatomy of the heart.

The heart is a muscular pump that contains four chambers: right atrium, left atrium,
right ventricle and left ventricle. The two small atria make up the top of the heart, and
the two large ventricles make up the bottom of the heart. The right atrium pumps
blood to the right ventricle, and the left atrium pumps blood to the left ventricle. A
wall, called the septum, separates the right atrium and right ventricle, from the left
atrium and left ventricle.

Blood flows through the heart in the following manner:

• The right atrium receives oxygen-poor blood from the body, and then pumps
the blood through the tricuspid valve and into the right ventricle.
• The right ventricle pumps the blood through the pulmonic valve and to the
lungs, where it picks up more oxygen.
• The left atrium receives the oxygen-rich blood from the lungs, and then pumps
the blood through the mitral valve and into the left ventricle.
• The left ventricle pumps blood through the aortic valve and to the rest of the
body.
• The blood supplies oxygen to the body and the cycle starts again.

Anatomy examples:

• Normal circulation through the heart

• The human heart
• Cross-section of heart at the level of the atria
• Cross-section of heart at the level of the ventricles
• The heart sits inside the pericardium
• The heart valves

Coronary Arteries
The coronary arteries supply oxygen to the heart muscle.

The heart has three main coronary arteries:

• Right coronary artery: supplies the right ventricle

• Left coronary artery: supplies the left ventricle
• Posterior circumflex artery: supplies the posterior aspect of both ventricles

Anatomy examples:

• Coronary angiogram
• Front view of the heart and coronary arteries
• Back view of the heart and coronary arteries

Cardiac Conduction System

An electrical impulse stimulates the muscle fibers in the heart to contract. The
impulse spreads through the heart in a very organized manner, so that the atria
contract first, followed by the ventricles.

The electrical impulse proceeds in the following manner:

• The electrical impulse originates at the sinoatrial (SA) node, which is located
in the wall of the right atrium. The SA node is the heart's natural pacemaker: it
regulates the heart rate.
• The impulse proceeds through the atria, stimulating them to contract.
• After the atria are stimulated to contract, the atrioventricular (AV) node slows
the electrical impulse before it proceeds to the ventricles. This pause allows
the ventricles to fill with blood before they contract. The AV node is located
between the atria and the ventricles.
• After the pause, the impulse then proceeds through the ventricles, stimulating
them to contract.

Anatomy examples:

• The cardiac conduction system

• EKG showing electrical activity of heart

Pathologic anatomy of cor pulmonale. Results of autopsies

Authors: P Vogt, J R Rüttner

Journal: Schweizerische medizinische Wochenschrift

In a Zurich autopsy study comprising 7947 adults (over 20-year-olds), cor pulmonale
was diagnosed in 8.9% (709 cases). In more than half of the cases the cor pulmonale
was caused by lung diseases associated with chronic bronchitis and emphysema or
with fibrosis of the lung. In 7 cases recurrent thromboembolism was the sole cause of
cor pulmonale, whereas in 103 cases additional lung diseases were involved. 7 cases
could be attributed to primary pulmonary hypertension. Cor pulmonale is, as a rule,
the result of multiple lung conditions. The lesions of pulmonary vessels in cor
pulmonale are produced either by parenchymatous lung changes (such as
pneumoconiosis, sarcoidosis, etc.) or by pulmonary hypertension.
Schweizerische medizinische Wochenschrift. 01/05/1977; 107(16):549-53.
ISSN: 0036-7672

Basic Anatomy & Physiology of the Lungs

Notes by Jim Clarke revised by David Nordin

The respiratory system has five basic functions

1. Provide an area for gas exchange between the air and the blood.
2. Moving air in and out of the gas exchange areas.
3. Protecting respiratory surfaces from dehydration, temperature changes.
Defending the body from invasion by pathogens.
4. Producing sounds for verbal communication and smells for olfactory
 sensations.
5. Assist in the regulation of blood volume and blood pressure.

I. THE UPPER AIRWAYS

A. Nose - external part of nose consists of nasal bones, frontal process of maxilla
(upper 1/3) and nasal cartilage, septal cartilage and fibrous tissue (lower 1/3)

The roof of nasal cavity is formed by nasal bones, maxilla and part of the
ethmoid bone. Floor of nasal cavity is formed by palatine bones & part of the
maxilla.

Openings of nose are called nares or nostrils. Nasal passages lined with hair
follicles in the anterior region of the nasal passages only. Anterior region lined
with stratified squamous epithelium. Posterior region of nasal cavity lined with
pseudostratified ciliated columnar epithelium. Cilia propel mucous toward the
nasopharynx. (Backward direction).

3 bones are present in the nasal cavity called turbinates or conchae.

Turbinates separate gas into several small streams creating a larger surface area
for heating, humidification
and filtration of inspired air.
Water vapor from expired air
condenses in the nose, which
retains heat and moisture for
the next inspiration.

The defense mechanism

involves a narrow hair-lined
airway combined with a sharp
turn which cause the air to be
filtered based on impaction, sedimentation and diffusion. The mucosal fluid has
a slight antibacterial property.

B. Para nasal sinuses- air filled cavities surrounding & communicating with the
nasal cavity. Sinuses produce mucus for nasal cavity and act as sound
resonating chambers.
There are 4 sinuses:
Maxillary - below each eye
Frontal - above each eye
Ethmoid - between the eyes and behind the nose
Sphenoid - behind the ethmoid sinuses

C. Oral cavity - teeth, gums, lips, most of the tongue (2/3).

Roof formed by hard and soft palate & uvula. Soft palate
prevents food & liquid from entering nose during
swallowing. Lined with stratified squamous epithelium.
Palatine tonsils located adjacent to uvula on each side.
Tonsils are collections of lymphoid tissue.
 D. The pharynx - located below the nasal cavity, behind the oral cavity and above
the vocal cords. Strictly a passageway. Made up of 3 parts:

1. Nasopharynx - posterior to nasal cavity & superior to the soft palate. Lined
with pseudostratified ciliated columnar epithelium. Adenoids (pharyngeal
tonsils) located in posterior nasopharynx. Eustachian tubes (auditory tube)
located here and connect middle ear to nasopharynx & serves to equalize
pressure in the middle ear.

2. Oropharynx - lies between the soft palate superiorly and the base of the
tongue inferiorly. Lingual tonsil located at the base of the tongue. Lined with
stratified squamous epithelium,

3. Laryngopharynx- lies between the base of the tongue and the entrance to the
esophagus. Lined with stratified squamous epithelium. Hyoid bone (horse-
shoe shaped) lies at the base of the laryngopharynx. Provides support to the
larynx (described below).

II. THE LOWER AIRWAYS

A. THE LARYNX - voice box located between base of tongue and the upper end
of the trachea (wind pipe). Acts as a passageway for air; works as a protective
mechanism against aspiration of food & liquids; generates sounds for speech.

Cartilages of larynx:

Thyroid - cover anterior larynx - upper thyroid

cartilage connects to the hyoid bone with
cartilaginous membrane material. Commonly
called the ‘Adam’s Apple’
Epiglottis - spoon shaped fibro cartilage
connected only at the base of the spoon so that it
can move up and down to open for speech and
breathing and close during swallowing preventing
aspiration of foods. There is a unique fold at the
base of the epiglottis used as a key landmark for
intubation called the vallecula.
Cricoid - signet ring shaped located at the base of the thyroid cartilage. Is
attached to the first c-shaped rings of the trachea itself. It is the only completely
circular ring of cartilage of the larynx. It comes in handy with intubations. Slight
downward pressure by a second person forces it posteriorly and the glottis to be
better viewed by the intubator. Also this act prevents regurgitation of stomach
contents by occluding the esophagus situated just behind the larynx.
Arytenoids - small pyramid shaped cartilages that provide support to the vocal
folds (cords) at the base of larynx. The arytenoid cartilage allows changes in the
tension on the vocal cords, allowing phonation and sphincter control, with the
interaction of the laryngeal muscles.
 Cuneiform & Corniculates- located slightly above the arytenoids; they also
provide support to the vocal folds.

The Cricothyroid ligament/membrane is the emergency procedure location

for an upper airway complete occlusion. You can insert a large bore needle or
cut with scalpel to provide an emergency airway for suctioning, supplemental
oxygen and ventilate the patient.

Vocal folds (cords) - Composed of central true cords and lateral false cords
(ventricular folds). Vocal cords attach superiorly to the posterior surface of the
thyroid surface and inferiorly to the arytenoid cartilage. The space between the
cords is called the glottis. In the adult the glottis is the narrowest point in the
larynx.
In the infant, the cricoid cartilage is the narrowest part of the larynx. The part
of the larynx just above the vocal cords is lined with stratified squamous
epithelium. Below the vocal cords, the mucosa is lined with pseudostratified
ciliated columnar epithelium.

Laryngeal musculature-
Extrinsic muscles pull down the larynx & hyoid bone to a lower
position in the neck. Intrinsic muscles - control the movements of the
vocal cords.

Closure (adduction) of the vocal cords (sealing off the airway) occurs
during lifting, pushing, coughing, throat-clearing, defecation, urination
and child-birth. This is also called Valsalva's maneuver.

B. THE TRACHEOBRONCHIAL TREE

1. Histology of airways - airways are generally composed of 3 layers:

a. Epithelial layer - lining layer (innermost). Composed of ciliated
pseudostratified columnar epithelium. Cilia begin to disappear as airways
become very small in diameter (< 1 mm). The bronchial glands are the
main producers of secretions in the respiratory tract. Interspersed between
these are mucous secreting cells called goblet cells. The mucous produced
by goblet cells covers the epithelial lining. Additional mucous is also
produced by sub-mucosal glands (see Lamina propria).
The mucous is composed of two layers - a watery outer layer called the sol
layer and a sticky viscous inner layer called the gel layer. Normally cilia
should beat within the thin sol layer allowing the mucous to move easily up
towards the throat

Each day we produce about 100 ml of mucous. Mucous normally moves at

about 2 cm/minute. The process of mucous movement is called the
mucociliary escalator.

Common things causing cilia to beat slowly or inconsistently thereby

decreasing mucous movement are:
Cigarette smoking dehydration
Positive pressure ventilation endotracheal suctioning
 High oxygen concentration hypoxia
Pollutants certain drugs (atropine) /
Anesthetics

At the bottom of the epithelial cells is a lining called the basement

membrane. This acts as a border between the epithelial layer and the next
layer called the:

b. Lamina propria layer (sub-mucosal layer) -

contains: loose fibrous tissue, tiny blood vessels,
lymphatic vessels, sub-mucosal glands and nerve
fibers. Also present are bands of spiral smooth
muscle fibers that wrap around the airway. These
muscles are present in virtually all airways,
however they are most important to the smaller
airways at which point cartilage is no longer
present (< 1 mm in diameter). When smooth
muscle fibers are irritated that may contract and
cause something called bronchospasm.

Also located in the laminal layer are mast cells. These are messenger cells
that when irritated (as occurs during allergic asthma attacks) may break open
releasing many very potent chemicals (including histamine) that create
swelling and bronchospasm itself.

c. Cartilaginous layer - outermost layer. It progressively diminishes as

airways extend out into the lungs and is generally totally absent in airways
less than 1 mm in diameter. This layer provides support to airways.

There are 2 major types of airways: Cartilaginous & Non-cartilaginous.

Cartilaginous airways - usually larger than 1 mm in diameter these airways are

generally called bronchi. Bronchi are surrounded by connective tissue sheaths.
Cartilage present in airway walls provides support and/or protection (preventing
collapse). All bronchi are supplied with blood by the bronchial arteries.

Non-cartilaginous airways – do not have a ring for support but instead use
traction of the surrounding elastic tissues and gas pressure gradient to keep the
airways open.

2. Conducting Zone -
Trachea - 11 to 14 cm in length; 1.5 to 2.5 in diameter. Splits (bifurcates) into
the main stem bronchi at the second anterior rib (at the level of the angle of
Louis). The bifurcation is called the carina. Trachea is made up 16 to 20 C-
shaped rings. The trachea shares a common posterior wall at the incomplete part
of the c-shaped rings with the esophagus.
Main-stem bronchi - right main-stem goes to the right lung; left main-stem to
left lung. C-shaped rings make up the outermost layer of each main stem
bronchi.
The angle from midline of the right mainstem is about 25 degrees while the
angle from midline for the left mainstem is between 40 - 60 degrees. As a result
aspirated materials tend to enter the right mainstem bronchi. Main-stem
bronchi are referred to as the tracheo-bronchial tree's first generation.

Lobar bronchi- right lung has three sections called lobes (upper, middle and
lower). Each section or lobe is supplied by lobar bronchi. Lobar bronchi have
cartilaginous plates in their walls rather than c-shaped rings. This is the second
generation.

Segmental bronchi- each lobe is divided into a variety of smaller areas called
segments. Each segment is supplied by a respective airway. There are 10
segments in the right lung and 8 segments in the left lung. This is the third
generation.

Sub-segmental
bronchi-
tracheobronchial tree
separates into
progressively smaller
airways from
Generation four
through nine. These
bronchi range in size
from 1-4 mm in
diameter.

Entering the non-

cartilaginous airways
zone

Non-cartilaginous
airways - usually
smaller than 1 mm in
diameter. Connective
tissue sheaths and
cartilage are no longer
present. Non-
cartilaginous airways
are present between
generations 10 through
23.

Types of non-cartilaginous airways

Bronchioles- Generations 10-15. These airways are not very rigid since no
cartilage is present and are prone to narrowing in disease. Bronchioles are
 generally surrounded and pass through the parts of the lungs that are made up of
air sacs (alveoli). The air sacs tend to hold the airways open (tethering effect).
Bronchioles receive their blood supply from the bronchial arteries.

Terminal bronchioles - Generations 16-20. These are the last purely

conducting airways. No gas exchange occurs in these structures. The average
diameter is about 0.5 mm. Cilia begin to disappear and epithelium changes to a
cuboidal flat shape. Some terminal bronchioles may have small openings or
channels in their walls called Canals of Lambert that connect with adjacent air
sacs. Clara cells are present in terminal bronchiole walls. These cells may act
to detoxify inhaled gases. They receive their blood supply from pulmonary
capillaries. Each terminal bronchiole is supplied by its own respective
pulmonary capillary.

3. Gas Exchange Zone

Respiratory bronchioles- Generations 21-23. These

airways have actual alveolar sacs imbedded in their walls
where gas exchange is taking place. No cilia are present.
Each respiratory bronchiole branches into three:

Alveolar ducts- each respiratory bronchiole bifurcates into 3

alveolar ducts.

Each terminal bronchiole with its complement of 3

respiratory bronchioles; 9 alveolar ducts and 1 pulmonary
capillary is called the "primary lobule" or acinus. Each
primary lobule has about 2000 alveoli. The area where gas
exchange occurs is called the "lung parenchyma".
There are approximately 300 million alveoli in the normal
adult lungs creating a surface area of approximately 70
square meters. Pulmonary capillaries cover about 80% of
the surface of each alveolus.

There are several forms of intercommunication channels so the alveoli are not
‘dead-ended’.
1. Intersegmental bronchioles – provide a collateral gas
movement and even distribution of gases.

2. Pores of Kohn- these are small openings between alveoli

allowing air, certain cells and fluid to move between adjacent air sacs.
The numbers of pores tend to increase with age indicating that these
may be the result of the aging process.

3. Canals of Lambert - connections of adjacent bronchioles

allowing for "collateral airflow".

Alveoli - made up of 3 types of cells

 Type 1- these are flat, very thin, fried-egg like cells that make up the largest
part (95%) of the alveolar walls. They have no known metabolic function.

Type 2- these are infrequent cells (5%) that are cuboidal in shape. They are
highly metabolic and are responsible for producing pulmonary surfactant.
Surfactant is critical in
maintaining the open
structure of alveoli by
decreasing surface tension
forces and preventing
collapse of air-sacs.
Premature newborns tend
to have an abnormally low
number of type 2 cells and
as a result their alveoli tend
to collapse during
breathing.

Type 3- (alveolar
macrophage) this is
actually a scavenger cell created in bone marrow that migrates to the lungs.
These cells engulf material that manages to land on the alveolar surface.

4. Interstitium

This is the term given to the spaces between alveoli. This area tends to be gel-
like and is composed of a web-like network of collagen fibers. The interstitium
is broken down into 2 compartments.

1. Tight space - the micro-thin areas in between alveolar walls and

their respective pulmonary capillaries.
2. Loose space - the areas occupied by lymphatic, nerve fibers,
vessels and that is not involved in gas exchange. This area can hold a
significant amount of non-vascular lung fluid.

III. FLUID CIRCULATION IN THE LUNGS

Lymphatic - Drain excess fluid and white cells from the interstitial spaces (both
deep and superficial vessels). They help to keep the lung "dry". Also it plays a
role (with the phagocytes) in removing bacteria, foreign material and cell debris
via the lymph fluid. This is why your lymph glands are swollen with some types
of infectious diseases. It drains into the thoracic duct. If the vessels are
overloaded and swollen with excessive fluid they can be seen on X-ray as
Kerley A or B lines. They normally can’t be seen on X-ray.

Bronchial circulation - the bronchial arteries provide nutrition to airways and

tissues down to the level of the terminal bronchioles. Bronchial veins drain this
same area.
 Pulmonary circulation - Arterioles and capillaries bringing blood to alveoli in
order to take part in gas exchange. Pulmonary arteries carry de-oxygenated
blood (low in oxygen & high in carbon dioxide) from the right ventricle of the
heart to the lungs. Pulmonary veins carry oxygenated blood (high in oxygen &
low in carbon dioxide) back from the lungs to the left atrium of the heart. This is
‘opposite’ of normal systemic arteries and veins.
Pressures in the normal pulmonary circulatory system average about one sixth
of that in the systemic circulation. Even thought the amount of blood is the
same, the pulmonary system offers much less resistance. High pulmonary
resistance is related to right heart failure and cor pulmonale.

The normal Partial Pressure of Oxygen (PaO2) is 80 - 100 mmHg (torr).

The normal PaCO2 is 35 - 45 mmHg (torr).

The normal PvO2 is 40 mmHg (torr).

The normal PvCO2 is 45 mmHg (torr).

The above values are for adults.

Virtually all of the output from the right heart (cardiac output is denoted
with the symbol (Q) passes through the lungs- normal Q at rest is approximately
5-6 l/m.

IV. THORACIC CAVITY & WALL

The thorax consists of three compartments:

1. Mediastinum
2. Right pleural cavity
3. Left pleural cavity
The thoracic cavity is formed by the ribs & sternum
anteriorly and the ribs and spine posteriorly. It is
narrower at the top and wider at the bases. The
superior margin is at the thoracic inlet at the base of
the neck. The inferior margin is formed by the
diaphragm. The thoracic cage serves two purposes.
First, its bony structure protects the vital organs
inside. Secondly, breathing is facilitated with
expansion and contraction of chest volume for
breathing (moving air in and out of lungs).

Thoracic cage is made up of:

a. The ribs: There are 12 ribs; 7 are true ribs
(articulating directly with the sternum); 3 are false
ribs (connecting with adjacent ribs and then with the sternum); 2 are floating
ribs (they do not connect with the sternum). The true and false ribs are
connected to the sternal body via the costo-chondral cartilage.
The ribs have a costal groove on the underside of each rib. This is where the
arteries, veins and nerves run. When puncturing through the ribs with a needle
during a thoracentesis the doctor must be on the top of the rib to avoid vessel
and nerve damage.
 The ribs move simultaneously about two axis – often referred to as ‘pump
handle’ and ‘bucket handle’ motion.
b. The sternum: Is a dagger-like structure that provides protection. Averages 18
cm in length. Has 3 parts: the upper manubrium, the body, and the lower
xyphoid process. Important landmarks are the suprasternal notch and the Angle
of Louis.
c. And the vertebral bodies of the thoracic spine.

V. LUNGS AND PLEURA

The lungs a paired, cone shaped organs. They are 90% gas and 10% tissue. The
left lung is somewhat narrower because of the heart. The right lung is slightly
elevated and thus shorter, due to the liver. The right lung has upper, middle and
lower lobes. The left lung only has an upper and lower lobe. They extend from
the diaphragm to 1 to 2 cm above the clavicles. They are divided into lobes
which are separated by one or more fissures. The right ling has the extra fissure
(because it has the extra lobe). The lingual of the left lobe corresponds to the
missing middle lobe of the right lung. Each lobe is subdivided into segments.
The right lung has 10 segments and the left only 8 segments. Lung landmarks of
note are the apex, the bases, and the costophrenic angle.

The lungs are covered with a very thin lining layer of mesothelial tissue called
the visceral pleura. The interior surface of the thoracic cavity is also lined with
a very thin mesothelial layer of tissue called the parietal pleura. The two pleural
surfaces adhere to one another based upon a slight suction. These cells produce
a lubricating fluid that allows the lungs to smoothly glide over the surface of the
thoracic cavity. The space between the pleural layers is referred to as the intra-
pleural space. Normally this is a "potential" space and as such it should have no
air present. Fluid entering the pleural space is normally drained via lymphatic
vessels.

The lungs, in addition to gas exchange, perform other functions.

1. They are a blood reservoir for the left ventricle of the heart
2. The lungs filter the blood and traps particles before they inflict damage
to other parts of the body (e.g. A clot traveling to the brain causing a
stroke)
3. The lungs play an active role in metabolism. They are responsible for
synthesis, activation, inactivation and detoxification of many bioactive
substances.
a. Heparin, histamine and serotonin are stored or synthesized in the
lung
b. Angiotensin is converted to its active form in the lung
c. Adenosine triphosphate (ATP) and norepinephrine ar partly
removed from the blood and inactivated by the lungs.

VI. MEDIASTINUM & HILUM

Mediastinum is the area between the lungs; below the thoracic inlet to the thorax
and above the diaphragm. It contains the heart; thymus gland; major vessels
 (pulmonary artery and pulmonary veins; ascending & descending aorta; inferior
& superior vena cava); nerves; trachea; esophagus and lymph nodes.

Hilum - the spot at which the main-stem bronchi enter each lung.

VII. BREATHING MUSCLES

Inspiratory- primary muscles: Diaphragm and abdominals. Diaphragm is
innervated via the phrenic nerve. Phrenic nerve exits the spine at points
between C2 & C5. Phrenic nerve bifurcates into two limbs once it enters the
thoracic cavity, transits across the thoracic cavity with each limb going to one-
half of the diaphragm. Each one-half is referred to as a "hemi-diaphragm".
The diaphragm is a very energy efficient muscle and rarely tires (except in
chronic lung disease).
The diaphragm only
moves 1 to 2 cm during
normal breathing but
accounts of 75% of the
change in thoracic
volume. The diaphragm
may become flattened
(and less efficient) with
air trapping with
obstructive diseases
(COPD).
Abdominal breathing is
taught to patients as an
efficient breathing
method. The internal
intercostals are used
during exercise so is not
considered primary.

Accessory muscles of
inspiration:
1. Neck muscles - scalenes, sternocleidomastoids, trapezius.
2. Chest muscles - pectoralis major.
These muscles are used by patients suffering from lung disease during periods
of exacerbation (a sudden worsening). They are very energy inefficient.
These muscles consume more oxygen and produce more CO2 than the primary
muscles of inspiration.

Expiratory muscles - normally exhalation is passive. Only during exercise or

stress does it become an active process. Abdominal muscles used are the rectus
abdominus; internal & external obliques and the transverse abdominus. These
muscles squeeze the abdominal contents and push up against the bottom of the
diaphragm. The external intercostals also assist by decreasing thoracic size
during exhalation.
VIII. LUNG VOLUMES & CAPACITIES-

TIDAL VOLUME (Vt) - the

amount of air exhaled during
normal relaxed breathing. (In
adults is about 350 to 600 ml).

VITAL CAPACITY (VC) - the

maximum amount of air that can
be exhaled after first taking a
maximal inhalation. (Normally
between 3000 to 6000 ml's in
adults).

RESIDUAL VOLUME (RV) -

the amount of air remaining in the
lungs after a maximal exhalation.
This volume will never "come-
out". Therefore it cannot be
directly measured. Other
"indirect" techniques must be
used to determine its size.

TOTAL LUNG CAPACITY

(TLC) - the amount of air present
in the lungs at the point at which a
person has taken a maximal
inhalation and is holding that
volume in their lungs. This is the sum of the RV + VC. Also must be indirectly
measured.

EXPIRATORY RESERVE VOLUME (ERV) - the additional amount of air

that can be forcibly exhaled after first completing a relaxed exhalation.

INSPIRATORY RESERVE VOLUME (IRV) - the additional amount of air

that can be inhaled after completing a normal inhalation.

FUNCTIONAL RESIDUAL CAPACITY (FRC) - the amount of air present in

the lungs after a normal relaxed exhalation. This is the sum of the RV + ERV.

INSPIRATORY CAPACITY (IC) - the amount of air that can be maximal

inhaled after completing a relaxed exhalation. This is the sum of the Vt + IRV.

IX. GAS PICKUP AND DELIVERY

The problem of delivering oxygen (and nutrients) to the cells and removing
carbon dioxide (and waste products) is solved by a handy transport system
where oxygen is bound to hemoglobin and carbon dioxide is chemically bound
or transported in the plasma of the blood. Thus the body had developed and
excellent gas exchange transport system.
X. CONTROL OF BREATHING -
 Central control - via the brain stem & medulla. This area receives impulses
from "sensors" located in the brain and peripherally; interprets the received
impulses and sends out messages to the respiratory muscles initiating breathing
and controlling the depth and rhythmicity of breathing.

Central Chemoreceptors - located in the brain stem, they are sensitive to

cerebral spinal pH. Since pH is most related to arterial carbon dioxide levels,
the central chemoreceptors are indirectly sensing PaCO2. As PaCO2 rises,
breathing rate & depth should increase and visa versa. The central
chemoreceptors normally account for how we breathe.

Peripheral Chemoreceptors - located at the bifurcation of the internal &

external carotid arteries in the neck. These specialized cells measure the PaO2
of blood and the arterial pH in the circulating blood. Normally they are not
active unless the PaO2 drops below 60-70 mmHg (torr). The lower the PaO2
drops below 60 mmHg, the more active they become.
When active, the peripheral chemoreceptors send impulses to the medulla
causing the rate & depth of respiration to increase. If the arterial pH drops
below 7.35, the same event occurs.

XI. VENTILATION TERMS -

MINUTE VENTILATION (VE) - THE VOLUME OF AIR EXHALED BY A

PATIENT IN ONE MINUTE. MAY BE CALCULATED BY
MULTIPLYING THE RESPIRATORY RATE TIMES THE TIDAL
VOLUME. (A dot "." appearing above any symbol means "per unit time"
usually per minute.
.
Vt x R.R. = VE

DEADSPACE - (Vds) the volume of each breath taken that does not take place
in gas exchange. (Usually is referred to as the anatomic deadspace.) This
amount corresponds to the volume of air present in conducting airways like the
nose, pharynx, larynx, trachea, mainstem bronchi, segmental bronchi, sub-
segmental bronchi & terminal bronchioles.

ALVEOLAR VENTILATION - ( VA) - the volume of air that actually takes

part in gas exchange each minute.
.
(VT - Vds) x R.R. = VA

Under normal conditions at rest this volume is 4-5 liters/minute in adults.

The V/Q ratio - expresses the relationship between the amount of ventilation
going to the lungs in the form of the air that we breathe compared to the amount
of blood flow passing through the lungs at the same time. Since normal VA
(alveolar minute ventilation) is 4 l/m and normal Cardiac Output (Q) is 5 l/m,
the normal V/Q ratio is expressed as 0.8. (There are no units to this number.)
In disease states of the heart &/or lungs, the V/Q value may be greater than .8
or less than .8. If it is > .8 it is called HIGH V/Q. If it is < .8 it is called
LOW V/Q. Patients who are experiencing problems with low oxygen levels
frequently are suffering from LOW V/Q.