Chapter 3 Pulmonary Circulation

First professional examination SAQs 1. Describe the peculiarities of pulmonary circulation? (D.U:08Ja) 2. How is pulmonary oedema formed? (D.U-05Ja) PHYSIOLOGIC ANATOMY OF THE PULMONARY CIRCULATORY SYSTEM

1. Pulmonary Vessels. The pulmonary artery divides into right and left main
branches that supply blood to the two respective lungs.

2. Bronchial Vessels. Blood also flows to the lungs through small bronchial
arteries that originate from the systemic circulation, amounting to about 1 to 2 per cent of the total cardiac output. It supplies the supporting tissues of the lungs. Lymphatics. Lymph vessels are present in all the supportive tissues of the lung, beginning in the connective tissue spaces that surround the terminal bronchioles, coursing to the hilum of the lung, and thence mainly into the right thoracic lymph duct. (Guyton)

3.

Why the flow into the left atrium and the left ventricular output are greater than the right ventricular output? After bronchial aarterial blood has passed through the supporting tissues, it empties into the pulmonary veins and enters the left atrium, rather than passing back to the right atrium. Therefore, the flow into the left atrium and the left ventricular output are about 1 to 2 per cent greater than the right ventricular output. Why pulmonary arterial tree have a large compliance?

a. The pulmonary artery is thin, with a wall thickness one third that of the
aorta.

b. The pulmonary arterial branches are very short, and all the pulmonary

arteries, even the smaller arteries and arterioles, have larger diameters than their counterpart systemic arteries.

These, combined with the fact that the vessels are distensible, gives the pulmonary arterial tree a large compliance, averaging almost 7 ml/mm Hg, which is similar to that of the entire systemic arterial tree. This large compliance allows the pulmonary arteries to accommodate the stroke volume output of the right ventricle. How pulmonary lymphatics help to prevent pulmonary edema? Particulate matter entering the alveoli is partly removed by way of these channels, and plasma protein leaking from the lung capillaries is also removed from the lung tissues, thereby helping to prevent pulmonary edema.(Guyton)

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DIFFERENCES OF PULMONARY FROM SYSTEMIC (PECULIARITIES OF PULMONARY CIRCULATION)

CIRCULATION

1. 2. 3. 4. 5. 6.

The pulmonary artery is thin The pulmonary arterial branches are very short pulmonary arteries and arterioles, have larger diameters Vessels are more distensible Vessels have larger capacity The pulmonary capillary pressure is low, about 7 mm Hg, in comparison with a considerably higher functional capillary pressure in the peripheral tissues of about 17 mm Hg. 7. The pulmonary capillaries are relatively leaky to protein molecules, so that the colloid osmotic pressure of the pulmonary interstitial fluid is about 14 mm Hg, in comparison with less than half this value in the peripheral tissues. 8. The systemic circulation consists of different types (muscular, elastic) of blood vessels, which branch into smaller sizes into all tissues. The pulmonary circulation consists of two main blood vessels, which branch off only into the lungs. 9. In the systemic circulation, arteries carry oxygenated blood to the tissues from the left ventricle of the heart. In the pulmonary circulation, the pulmonary artery carries deoxygenated blood to the lungs via the right ventricle. 10. In the systemic circulation, veins carry deoxygenated blood to the heart, emptying into the right atrium of the heart. In the pulmonary circulation, the pulmonary vein carries oxygenated blood to the heart, emptying into the left atrium. 11. The systemic circulation not only delivers oxygen to the tissues (exchanging it for carbon dioxide), but it picks up nutrients from other tissues, such as the intestines, and delivers cellular wastes to the kidneys. The pulmonary circulation is concerned primarily with gas exchange, making it more specialized. 12. Though the circulation in the lungs consists of a lot of surface area to fulfill its functions (an estimated 500-1000 square feet of capillary surface area), the systemic circulation is larger. In total, all of the blood vessels in the body are estimated to cumulatively stretch to 60,000 miles in length 13. In capillary larger, multiple anastomosis 14. flow is more pulsatile than in the systemic circuit

PULMONARY BLOOD PRESSURE Low pressure in arteries and capillaries (compared with systemic circulation) e.g. at rest Pressure Arterial pressure Capillary pressure Venous pressure Systemic 120/80 mean mmHg; 95 mmHg Pulmonary 25/8 mmHg; 15 mmHg mean 7 mmHg mean 2-5 mmHg

17 mmHg mean 2-5 mmHg

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ZONES OF THE LUNG The zones of the lung proposed by West in 1964, divide the lung into three vertical regions, based upon the relationship between the pressure in the alveoli (PA), in the arteries (Pa), and the veins (Pv): #1: alveolar > arterial > venous #2: arterial > alveolar > venous #3: arterial > venous > alveolar

The ventilation/perfusion ratio is higher in zone #1 (the apex of lung when a person is standing) than it is in zone #3 (the base of lung.)

1. Zone 1 does not normally exist. In normal health pulmonary arterial pressure
exceeds alveolar pressure in all parts of the lung. It generally only exists when a person is ventilated with positive pressure. Blood vessels are completely collapsed by alveolar pressure and blood does not flow through these regions. They become alveolar dead space. Zone 2 is the part of the lungs above about 3cm above the heart. In this region blood flows in pulses. At first there is no flow because of obstruction at the venous end of the capillary bed. Pressure from the arterial side builds up until it exceeds alveolar pressure and flow resumes. This dissipates the capillary pressure and returns to the start of the cycle. Zone 3 comprises the majority of the lungs in health. There is no external resistance to blood flow and blood flow is continuous throughout the cardiac cycle (West, Dollery, Naimark 1964). BALANCE OF FORCES AT THE BLOOD CAPILLARY MEMBRANE Pressure (mm Hg) Forces tending to cause movement of fluid outward from the capillaries and into the pulmonary interstitium: Capillary pressure 7 Interstitial fluid colloid osmotic pressure 14 Negative interstitial fluid pressure 8 TOTAL OUTWARD FORCE 29 Forces tending to cause absorption of fluid into the capillaries: Plasma colloid osmotic pressure 28 TOTAL INWARD FORCE 28 Forces Mean Filtration Pressure (Total Outward Force- Total Inward Force) 1

2.

3.

PULMONARY EDEMA Pulmonary edema is a condition associated with increased loss of fluid from the pulmonary capillaries into the pulmonary interstitium and alveoli.

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Mechanism: Pulmonary edema occurs in the same way that edema occurs elsewhere in the body. Any factor that causes the pulmonary interstitial fluid pressure to rise from the negative range into the positive range will cause rapid filling of the pulmonary interstitial spaces and alveoli with large amounts of free fluid.

The most common causes of pulmonary edema are as follows: 1. Left-sided heart failure or mitral valve disease, with consequent great increases in pulmonary venous pressure and pulmonary capillary pressure and flooding of the interstitial spaces and alveoli.

2.

Damage to the pulmonary blood capillary membranes caused by infections such as pneumonia or by breathing noxious substances such as chlorine gas or sulfur dioxide gas. Each of these causes rapid leakage of both plasma proteins and fluid out of the capillaries and into both the lung interstitial spaces and the alveoli. (Ref Guyton & Hall, 11th edition) References: References: West J, Dollery C, Naimark A. 1964. "Distribution of blood flow in isolated lung; relation to vascular and alveolar pressures". J Appl Physiol 19: 713 19: 24.

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