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Functional anatomy of pulmonary system, pulmonary circulation and mechanics of breathing

Presenter: Dr. Satyajit Majhi Moderator: Dr. J.P. Sharma

University College of Medical Sciences & GTB Hospital, Delhi


www.anaesthesia.co.in Email: anaesthesia.co.in@gmail.com

5 Functions of the Respiratory System


1. Provides extensive gas exchange surface area between air and circulating blood 2. Moves air to and from exchange surfaces of lungs 3. Protects respiratory surfaces from outside environment 4. Produces sounds 5. Participates in olfactory sense

The Nose
Air enters the respiratory system:
through nostrils or external nares into nasal vestibule

Nasal hairs:
are in nasal vestibule are the first particle filtration system

The Nasal Cavity


The nasal septum:

divides nasal cavity into left and right Superior portion of nasal cavity is the olfactory region: provides sense of smell Mucous secretions from par nasal sinus and goblet cells: clean and moisten the nasal cavity
Lined by ciliated mucosal layer

Epistaxis
Most common site Littles area Situated anterior inferior part of nasal septum. Anastomosis of 4 arteries, anterior ethmoidal, septal branch of superior labial, septal branch of sphenopalatine and greater palatine. Woodruff area, anastomosis of sphenopalatine artery and posterior pharyngeal artery causes posterior epistaxis

Air Flow
Meatuses
Constricted passageways that produce air turbulence:
warm and humidify incoming air trap particles

During exhalation these structures:


Reclaim heat and moisture Minimize heat and moisture loss

The Palates
Hard palate:
forms floor of nasal cavity separates nasal and oral cavities

Soft palate:
extends posterior to hard palate divides superior nasopharynx from lower pharynx

Nasal Cavity

The Pharynx and Divisions


A chamber shared by digestive and respiratory systems Extends from internal nares to entrances to larynx and esophagus Nasopharynx Oropharynx Laryngopharynx

The Nasopharynx
Superior portion of the pharynx Contains pharyngeal tonsils and openings to left and right auditory tube Pseudo-stratified columnar epithelium The Oropharynx Middle portion of the pharynx Communicates with oral cavity Stratified squamous epithelium The Laryngopharynx Inferior portion of the pharynx Extends from hyoid bone to entrance to larynx and esophagus

Air flow from the pharynx, enters the larynx: a cartilaginous structure that surrounds the glottis

Cartilages of the Larynx


3 large, unpaired cartilages form the larynx:
the thyroid cartilage the cricoid cartilage the epiglottis

ANATOMY OF LARYNX

ANATOMY OF LARYNX

The Thyroid Cartilage


Also called the Adams apple Is a hyaline cartilage Forms anterior and lateral walls of larynx Ligaments attach to hyoid bone, epiglottis, and laryngeal cartilages

The Cricoid Cartilage


Is a hyaline cartilage Form posterior portion of larynx Ligaments attach to first tracheal cartilage Articulates with arytenoid cartilages

The Epiglottis
Composed of elastic cartilage Ligaments attach to thyroid cartilage and hyoid bone

Cartilage Functions
Thyroid and cricoid cartilages support and protect:
the glottis the entrance to trachea

During swallowing:
the larynx is elevated the epiglottis folds back over glottis

Prevents entry of food and liquids into respiratory tract

3 pairs of Small Hyaline Cartilages of the Larynx arytenoid cartilages, corniculate (Santorini) cartilages and Cuneiform (Wrisberg) cartilages

Cartilage Functions
Corniculate and arytenoid cartilages function in: opening and closing of glottis production of sound

The Glottis

Ligaments of the Larynx


Vestibular ligaments and vocal ligaments:
extend between thyroid cartilage and arytenoid cartilages are covered by folds of laryngeal epithelium that project into glottis
1) The

Vestibular Ligaments

Lie within vestibular folds:


which protect delicate vocal folds

Speech
Speech intermittent release of expired air while opening and closing the glottis Pitch determined by the length and tension of the vocal cords Loudness depends upon the force at which the air rushes across the vocal cords The pharynx resonates, amplifies, and enhances sound quality Sound is shaped into language by action of the pharynx, tongue, soft palate, and lips

The Laryngeal Musculature


Laryngeal muscle can be Extrinsic muscles that
Elevates or depresses the hyoid bone

Intrinsic muscles that:


control vocal folds open and close glottis

Coughing reflex: food or liquids went down the wrong pipe

Nerve supply of Larynx


Mucous membrane above vocal fold internal laryngeal branch of superior laryngeal branch of vagus nerve Below that its supplied by recurrent laryngeal nerve (RLN) All intrinsic muscle, except cricothyroid RLN, cricothyroid by external laryngeal branch of SLN

Laryngeal paralysis
UNILATERAL
Cords remain in median or para-median position Asymptomatic UNILATERAL Ipsilateral cricothyroid muscle and anaesthesia of larynx above the vocal cord Asymptomatic

RLN

BILATERAL

Cords remain in median or para-median position Dyspnoea and stridor, voice good

SLN
BILATERAL Both cricothyroid muscle paralysis and anaesthesia of upper larynx Aspiration of food and weak voice

COMBINED
UNILATERAL
Cord remains in cadaveric position, 3.5 mm from midline and unilateral paralysis of all muscle except interarytenoid Hoarsness of voice, aspiration and ineffective cough

BILATERAL
All laryngeal muscle paralysed, both vocal cord lie in cadaveric position and total anaesthesia of larynx Aphonia, aspiration, inability to cough, bronchopneumonia

Sphincter Functions of the Larynx


The larynx is closed during coughing, sneezing, and Valsalvas maneuver Valsalvas maneuver
Air is temporarily held in the lower respiratory tract by closing the glottis Causes intra-abdominal pressure to rise when abdominal muscles contract Helps to empty the rectum Acts as a splint to stabilize the trunk when lifting heavy loads

Organization of the Respiratory System


The respiratory system is divided into the upper respiratory system, above the larynx, and the lower respiratory system, from the larynx down

The Respiratory Tract


Consists of a conducting portion:
from nasal cavity to terminal bronchioles

Transitional portion the respiratory bronchioles and alveolar ducts Respiratory portion:
the alveoli and alveolar sac

Alveoli
Are air-filled pockets within the lungs
where all gas exchange takes place

The Trachea
Extends from the cricoid cartilage into mediastinum
Formed of rings of cartilages, incomplete posteriorly Lined by ciliated columnar epithelium It bifurcates into right and left main bronchi at the level of T5

The Tracheal Cartilages


1520 tracheal cartilages:
strengthen and protect airway discontinuous where trachea contacts esophagus

Ends of each tracheal cartilage are connected by:


an elastic ligament and trachealis muscle

The Primary Bronchi


Right and left primary bronchi:
separated by an internal ridge (the carina)

The Right Primary Bronchus Is larger in diameter and shorter (2.5 cm) than the left Descends at a steeper angle (25) The Left Primary Bronchus Is narrower and longer (5cm) Descends at broader angle (55)

Bronchi subdivide into secondary bronchi, each supplying a lobe of the lungs Air passages undergo 23 orders of branching in the lungs Tissue walls of bronchi mimic that of the trachea As conducting tubes become smaller, structural changes occur
Cartilage support structures change Epithelium types change

Amount of smooth muscle increases

Secondary Bronchi
Branch to form tertiary bronchi, also called the segmental bronchi Each segmental bronchus:
Supplies air to a single bronchopulmonary segment
The right lung has 10 The left lung has 8 or 9

Division of primary bronchus


Right primary bronchus: a) Upper lobe: b) Middle lobe: c) Lower lobe : Apical bronchus Medial basal bronchus Anterior basal bronchus Posterior basal bronchus Lateral basal bronchus Lateral bronchus Medial bronchus c) Lower lobe: Apical bronchus Anterior basal bronchus Posterior basal bronchus Lateral basal bronchus Apical bronchus Posterior bronchus Anterior bronchus b) Lingula: Superior bronchus Inferior bronchus a) Left primary bronchus Upper lobe: Apical bronchus Posterior bronchus Anterior bronchus

Bronchial Structure
The walls of primary, secondary, and tertiary bronchi:
contain progressively less cartilage and more smooth muscle increasing muscular effects on airway constriction and resistance

The Bronchioles
Each tertiary bronchus branches into multiple bronchioles
1 tertiary bronchus forms about 6500 terminal bronchioles

Bronchioles branch into terminal bronchioles

Bronchiole Structure
Bronchioles:
have no cartilage are dominated by smooth muscle

Autonomic Control
Regulates smooth muscle:
controls diameter of bronchioles controls airflow and resistance in lungs

Bronchodilation
Dilatation of bronchial airways Caused by sympathetic ANS activation Reduces resistance

Bronchoconstriction
Constricts bronchi Caused by:
parasympathetic ANS activation histamine release (allergic reactions)

Pulmonary Lobules
Are the smallest compartments of the lung Are divided by the smallest trabecular partitions (interlobular septa) Each terminal bronchiole delivers air to a single pulmonary lobule Each pulmonary lobule is supplied by pulmonary arteries and veins

Exchange Surfaces
Within the lobule:
each terminal bronchiole branches to form several respiratory bronchioles, where gas exchange takes place

Alveolar Organization
Respiratory bronchioles are connected to alveoli along alveolar ducts Alveolar ducts end at alveolar sacs: common chamber connected to many individual alveoli

An Alveolus
Has an extensive network of capillaries Is surrounded by elastic fibers

Alveolar Epithelium
Consists of simple squamous epithelium Consists of thin, delicate Type I cells Patrolled by alveolar macrophages, also called dust cells Contains septal cells (Type II cells) that produce Surfactant- an oily secretion which
Contains phospholipids and proteins Coats alveolar surfaces and reduces surface tension

Respiratory Membrane - The thin membrane of


alveoli where gas exchange takes place
3 Parts of the Respiratory Membrane Squamous epithelial lining of alveolus Endothelial cells lining an adjacent capillary Fused basal laminae between alveolar and endothelial cells Diffusion- Across respiratory membrane is very rapid:
because distance is small gases (O2 and CO2) are lipid soluble

Blood Supply to Respiratory Surfaces


Each lobule receives an arteriole and a venule
1. respiratory exchange surfaces receive blood:
from arteries of pulmonary circuit

2. a capillary network surrounds each alveolus:


as part of the respiratory membrane

3. blood from alveolar capillaries:

passes through pulmonary venules and veins


returns to left atrium

Gross Anatomy of the Lungs


Left and right lungs: are in left and right pleural cavities The base: inferior portion of each lung rests on superior surface of diaphragm

The Root of the Lung


Site of attachment of bronchus, nerves, and vessels in hilus:
anchored to the mediastinum

Lung Shape
Right lung:
is wider is displaced upward by liver

Left lung:
is longer is displaced leftward by the heart forming the cardiac notch

Pleural Cavities and Pleural Membranes


2 pleural cavities:
are separated by the mediastinum

Each pleural cavity:


holds a lung is lined with a serous membrane (the pleura)

Pleura consist of 2 layers:


parietal pleura visceral pleura

Pleural fluid:
lubricates space between 2 layers

Blood supply to lungs


Lungs are perfused by two circulations: pulmonary and bronchial Pulmonary arteries supply systemic venous blood to be oxygenated
Branch profusely, along with bronchi Ultimately feed into the pulmonary capillary network surrounding the alveoli

Pulmonary veins carry oxygenated blood from respiratory zones to the heart

Blood supply to lungs


Bronchial arteries provide systemic blood to the lung tissue
Arise from aorta and enter the lungs at the hilus Supply all lung tissue except the alveoli

Bronchial veins anastomose with pulmonary veins Pulmonary veins carry most venous blood back to the heart

Pulmonary Circulation
Thin walled vessels at all levels. Pulmonary arteries have far less smooth muscle in the wall than systemic arteries. Consequences of this anatomy- the vessels are:
Distensible. Compressible. Low intravascular pressure.

Influences on Pulmonary Vascular Resistance


Vessel diameter influenced by extra vascular forces:
Gravity Body position Lung volume Alveolar pressures/intrapleural pressures Intravascular pressures

Control of pulmonary vascular resistance


Passive influence on PVR
Influence
Lung Volume
(above FRC)

Effect on PVR
Increase

mechanisim
Lengthening and Compression

Lung Volume

(below FRC)

Increase

Compression of Extra alveolar Vessels


Recruitment and Distension Recruitment and Distension

Flow, Pressure Gravity

Decrease Decrease in Dependent Regions Increase Increase

Interstitial Pressure Positive Pressure Ventilation

Compression Compression and Derecruitment

Gravity, Alveolar Pressure and Blood Flow


Pressure in the pulmonary arterioles depends on both mean pulmonary artery pressure and the vertical position of the vessel in the chest, relative to the heart. Driving pressure (gradient) for perfusion is different in the 3 lung zones: Flow in zone 1 may be absent because there is inadequate pressure to overcome alveolar pressure. Flow in zone 3 is continuous and driven by the pressure in the pulmonary arteriole pulmonary venous pressure. Flow in zone 2 may be pulsatile and driven by the pressure in the pulmonary arteriole alveolar pressure (collapsing the capillaries).

Control of Pulmonary Vascular Resistance


Active Influences on PVR: Increase
Sympathetic innervation - adernergic agonist Thromboxane/PGE2

Decrease
Parasympathetic innervation Acetylcholine - adrenergic agents PGE1 Prostacycline Nitiric oxide

Endothelin
Angiotensin Histamine

Alveolar hypoxemia

Bradykinin

Hypoxic Pulmonary Vasoconstriction


Alveolar hypoxia causes active vasoconstriction at level of precapillary arteriole. Mechanism is not completely understood: Response occurs locally and does not require innervation. Mediators have not been identified. Graded response between pO2 levels of 100 down to 20 mmHg. Functions to reduce the mismatching of ventilation and perfusion. Not a strong response due to limited muscle in pulmonary vasculature. General hypoxemia (high altitude or hypoventilation) can cause extensive pulmonary artery vasoconstriction.

Regulation of breathing
Medullary rhythmicity center
Nerves extend to intercostals and diaphragm Signals are sent automatically Expiratory center is activated during forced breathing

Pneumotaxic area
Controls degree of lung inflation; inhibits inspiration

Apneustic area
Promotes inspiration

Chemoreceptors
Breathing can be controlled voluntarily, up to a point Too much CO2 and H+ will stimulate inspiratory area, phrenic and intercostal nerves Central chemoreceptors: medulla oblongata monitors CSF

Peripheral chemoreceptors
Aortic bodies (vagus nerve) Carotid bodies (glossopharyngeal nerve) Respond to fluctuations in blood O, CO2 and H levels Rapid respond Pulmonary stretch receptors prevent over inflation of lungs (promote expiration)

Pulmonary ventilation
Inhalation:
always active

Exhalation:
active or passive

3 Muscle Groups of Inhalation


1. Diaphragm:
contraction draws air into lungs Increases transverse diameter of thorax 75% of normal air movement assist inhalation 25% of normal air movement
sternocleidomastoid serratus anterior pectoralis minor scalene muscles

2. 3.

External intercostals muscles:



Accessory muscles assist in elevating ribs:

Muscles of Active Exhalation


1. Internal intercostal and transversus thoracis muscles:
depress the ribs and decreases thoracic volume

2. Abdominal muscles:
compress the abdomen force diaphragm upward Forcefully contracts while coughing and sneezing

Inspiration

Expiration

Ventilation
Depends on

Lung volume Alveolar ventilation Anatomic and physiological dead space Regional difference in ventilation

Lung volume
Total lung volume is divided into a series of volumes and capacities useful in diagnosis in pulmonary function tests

Measure rates and volumes of air movements

4 Pulmonary Volumes
1. Resting tidal volume:

in a normal respiratory cycle


after a normal exhalation after maximal exhalation minimal volume (in a collapsed lung) after a normal inspiration

2. Expiratory reserve volume (ERV):

3. Residual volume:

4. Inspiratory reserve volume (IRV):

4 Calculated Respiratory Capacities


1. Inspiratory capacity: tidal volume + inspiratory reserve volume 2. Functional residual capacity (FRC): expiratory reserve volume + residual volume 3. Vital capacity: expiratory reserve volume + tidal volume + inspiratory reserve volume 4. Total lung capacity: vital capacity + residual volume Closing capacity: Minimum volume at which smaller airways begin to close and causes air trapping.

Respiratory Volumes and capacities

Alveolar Ventilation
Amount of air reaching alveoli each minute Calculated as: AV= RR X (TV DV) = 12 X (500-150) = 4200 ml/min Alveoli contain less O2, more CO2 than atmospheric air:
because air mixes with exhaled air

Alveolar Ventilation Rate


Determined by respiratory rate and tidal volume:
for a given respiratory rate:
increasing tidal volume increases alveolar ventilation rate

for a given tidal volume:


increasing respiratory rate increases alveolar ventilation

Dead space
Anatomical
Volume of conducting airway Its about 150ml

Physiological
Volume of gas that does not eliminate CO Volume is same as above It is increased in many lung disease

Mechanics of breathing
Depends on Pressure volume curve Compliance

Elastic properties of chest wall


Surface tension Resistance

Pressure volume curve


The pressure volume curve varies between apex and base of the lung. At the base the volume change is greater for a given change in pressure. Hence alveolar ventilation declines with height from base to apex. This is because at the base the lungs are slightly compressed by the diaphragm so upon inspiration have greater scope to expand. Thus a small change in intrapleural pressure brings about a relatively large change in volume

Elastance Physical tendency to return to original state after deformation

Lung volume at any given pressure is slightly more during deflation than it is during inflation, it is called Hysteresis (due to surface tension)

Compliance
An indicator of expandability V/P (200 ml/ cm HO) Low compliance requires greater force High compliance requires less force

Factors Governing Compliance


1. 2. 3. Connective-tissue structure of the lungs Level of surfactant production Mobility of the thoracic cage

Factors That Diminish Lung Compliance


Fibrosis or scar tissue in lung Decrease surfactant Restricted movement of chest wall

Deformity of thorax
Ossification of costal cartilages Paralysis of intercostal muscles Blockage of smaller air way

Elastic properties of chest wall


Lung has a tendency to collapse inward and chest wall springs out ward FRC is the equilibrium volume where both force balance each other Chest wall tends to expand at volumes up to about 75% of total vital capacity

Surface tension
Surfactant reduces surface tension forces by forming a monomolecular layer between aqueous fluid lining alveoli and air, preventing a water-air interface

Produced by type II alveolar epithelial cells


Complex mix-phospholipids, proteins, ions
dipalmitoyl lecithin, surfactant apoproteins, Ca++ ions

Stabilization of Alveolar size


Role of surfactant
Law of Laplace P=2T/r

Without surfactant smaller alveolar have increased collapse & would tend to empty into larger alveoli
Big would get bigger and small would get smaller

Surfactant automatically offsets this physical tendency


As the alveolar size surfactant is concentrated which surface tension forces, off-setting the in radius

Resistance
Airway resistance

Or
Tissue resistance

Airway resistance
Friction is the major nonelastic source of resistance to airflow The relationship between flow (F), pressure (P), and resistance (R) is:

P F=R

The amount of gas flowing into and out of the alveoli is directly proportional to P, the pressure gradient between the atmosphere and the alveoli

Gas flow is inversely proportional to resistance with the greatest resistance being in the medium-sized bronchi

As airway resistance rises, breathing movements become more strenuous Severely constricted or obstructed bronchioles:
Can prevent life-sustaining ventilation Can occur during acute asthma attacks which stops ventilation

Epinephrine release via the sympathetic nervous system dilates bronchioles and reduces air resistance

Tissue resistance
Due to tissue displacement during ventilation (lungs, thorax, diaphragm) It is the 20% of total resistance Mainly from lung tissue resistance and chest wall resistance Air flow resistance is around 1 cm HO/L/sec Increases up to 5 folds in obstructive lung disease by obesity, fibrosis, ascites

Work of breathing
Done by respiratory muscles to over come elastic and frictional forces opposing inflation.
W= F X S ( force X distance) = P X V = area under P-V curve

Normal breathing
active inhalation passive exhalation (work of exhalation recovered from potential energy stored in expanded lungs & thorax during inspiration)

Area 1 = work done against elastic forces ( compliance) = 2/3 Area 2 = work done against frictional forces ( resistance work) =1/3 Area 1+2 = total work done = 2/3 + 1/3 = 1

TV elastic component of work RR ( flow) frictional work People with diseased lungs assume a ventilatory pattern optimum for minimum work of breathing. COPD/Obstructive disease-Slow breathing with pursed lips( frictional work) Fibrosis/Restrictive disease-Rapid shallow breathing(elastic work)

References
Millers Anesthesia- Ronald D. Miller 7th edition Respiratory physiology- John B. West, 8th edition A Practice of Anesthesia- Wylie and Chuchill Davidson, 5th edition

www.anaesthesia.co.in

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