applied respiratory physiology: part 1 by; dr mohd ridhwan bin mohd noor intensivist hsnz 2013 pre...
TRANSCRIPT
Applied respiratory physiology: part 1
by;
Dr Mohd Ridhwan bin Mohd Noor
Intensivist
HSNZ 2013
Pre master basic science
Ouchh!
Knowledge decay after specialist graduation
Content
1. Functional anatomy
2. Deadspace/ lung volumes/ shunts
3. Ventilation/perfusion abnormalities
4. Control of respiration
5. Non respiratory functions of lungs
Functional anatomy
• Nose, mouth & pharynx humidify & filter the air gases
• Larynx is 18 mm in diameter & 11 cm in length
• Trachea divides to main stem bronchus at carina (T4)
• Bronchi divides 23 times (generations) & the first 16 are
termed conducting zone & forms anatomical deadspace
• Generation 17-23 where gas exchange occurs with 300
million alveoli & about 2-3 litres in volume
• Consists of 3 type of cells;
1. Type 1
• Provide thin layer of cytoplasm & cover 80% of gas
exchange zone
2. Type 2
• Formation of surfactant & other enzymes
3. Type 3
• Maintain lungs defense system – alveolar
macrophages
Weibels classification of airways
Clinical points
• ETT should be 1-2 cm above carina or at T3
• Right main bronchus divides from trachea at less acute
angle, therefore prone to endobronchial intubation
• ® upper lobe bronchus arises few cm from carina,
therefore for one lung ventilation (L) double lumen
ETT is favored to avoid risk of ® upper lobe collapse
with ® double lumen tube
Dead space
• Def; lung volume that does not participate in gas
exchange (wasted ventilation) or ventilation without
perfusion
• Types:
1. Anatomical deadspace
2. Physiological deadspace
3. Alveolar deadspace
4. Apparatus deadspace
Anatomical deadspace
• Volume of conducting airways (150 mls in
adults)
• Mostly atmospheric gas & it’s exhaled gas
before CO2 flowing to the alveoli & expired
• Influenced by age, position, height,
hypoventilation, atropine, hypothermia
Fowler’s methods (anatomical deadspace)
• Subject breathing to
pneumatachograph &
rapid nitrogen analyser
• Subject breaths 100%
of O2 & N2
concentration plotted
against time & volume
Alveolar deadspace
• Part of inspired gas that enter the alveoli BUT
does not participate in gas exchange
• Represents ventilated but underperfused alveoli
• Can be measured by comparing PAO2 & PaCO2
• Negligible in healthy adult & PACO2 almost
equal PaCO2
Causes ETCO2 < PaCO2
1. Low cardiac output or hypotension
2. High inspiratory pressure esp high PEEP
3. Pulmonary embolus
4. Posture changes – leading to changes in
regional perfusion
Physiological deadspace
• Alveoli + anatomical deadspace
• Part of tidal volume not participate in gas exchange
• Calculated using Bohr equation;
Vd = PaCO2 – PECO2
Vt PaCO2
• Normally ~ 30% of tidal volume
• Clinical: increase in physio deadspace cause alveolar ventilation
reduced unless compensatory increase in minute volume e.g. COPD
Lung volumes
Spirometry Tacing in adult male
Lung volumes
The volume (per kg)
• Residual volume 15-20 mls
• Expiratory reserve volume
15 mls
• Tidal volume 6-8 mls
• Inspiratory reserve volume
45 mls
The capacities (per kg)
• Total lung capacity 75-80
mls
• Vital capacity 60-70 mls
• Inspiratory capacity 50 mls
• Funtional residual capacity
30 mls
Which volumes & capacities can’t be measured by spirometry?
1. Residual volume
2. Any capacities which contain residual
volumes
– FRC
– Total Lung Capacity (TLC)
Functional residual capacity (FRC)
• Def: volume of gas which remains at the end
of normal expiration (FRC = RV + ERV)
• It is a balance point between tendency of
the chest wall to move outward & tendency
of the lungs to collapse
Forces exerted on the thorax
The tendency of the chest wall and diaphragm to separate from the lungs is the reason why intrapleural pressure is negative
Functions of FRC
1. Oxygen store
2. Buffer to maintain a steady arterial pO2
3. Prevent atelectasis
4. Minimise work of breathing (by keeping the lungs on
the steep part of the compliance curve)
5. Minimise pulmonary vascular resistance
6. Minimise V/Q mismatch
1. FRC as oxygen store
• At room air PAO2 of 100 mmHg & FRC of 2200 mls,
the lungs contain 290 mls of O2.
• Pre-oxygenation with 100%, it can increase up to
1800 mls of O2 in the lungs
2. Buffer for arterial PO2
• Continuous presence of gas containing in
the lungs converts the intermittent tidal
delivery into continuous availability of O2
for gas exchange.
• Prevent large swings in PaO2 during
ventilatory cycle
3. Prevent atelectasis
• FRC maintain partial state of partial inflation
in the lungs & prevent atelectasis
• At a balance point between the tendency of
the chest wall to move outward & the
tendency of the lung to collapse
4. Minimize work of breathing
– At FRC, the lung work at the steep part of
compliance curve
5. Minimise pulmonary vascular resistance
– PVR varies with lung volume, high at both high
and small lung volume
– PVR lowest at FRC
PVR & lung volume
6. Minimize V/Q mismatch
– FRC prevent lung closure at tidal ventilation &
minimize ventilation abnormality
Measurement of FRC
1. Gas dilution methods (nitrogen washout/helium
washin)
– Subject rebreathing from closed circuit that contain
initial volume (V1) & concentration of helium (He1)
– After period of rebreathing final helium (He2)
measured
V1 x (He1) = (V1 + FRC) x (He2)
Factors affecting FRC
Increase
• Height
• Changing from supine to
erect position
• Decreased lung elastic
recoil (e.g. emphysema)
• PEEP
Decrease
• Obesity
• Muscle paralysis
• Changing from erect to supine
• Pregnancy
• Anaesthesia
• Pulmonary ds causing
increased elastic recoil of the
lungs
2. Body plethysmography
Closing capacity
• Lung volume at which airways start to close in
expiration ( CC = CV + RV)
• Factors increasing CC;
– Increasing age
– Smoking/asthma/emphysema/bronchitis
– Prolonged recumbency
– Increase left atrial pressure
Closing volume measurement
Single breath Nitrogen washout
Relationship between FRC and closing capacity
66 yrs
44 yrs
Ventilation-perfusion abnormalities
Describe West’ zones of the lung
• Describe relationships of pulmonary arterial, venous
& alveolar pressure in zones from apex to the base
• Changes occur due to gravity that cause distension
of vessels at the upright lung base & compression at
the apex
• PAP decrease by 1 cmH2O per cm vertical distance
of the lung
• At the base PAP 10 cmH2O (16 26) & PVP
fr 11-21 cmH2O
• At the apex PAP 15 cmH2O (16 1) &
venous pressure fr. 11 to -4 cmH20
# need to put head down position to avoid air embolism
during CVC insertion#
West’s zones
• Zone 1: alveolar
pressure exceed
arterial pressure.
Creating no flow in
apex and deadspace
# Contribute to deadspace. Rarely occur in healthy subject but in hypotension, hemorrhage or use of PEEP will increase zone 1.#
West’s zones
• Zone 2; Pa exceeds PA
but PA still above PV on
expiration. The flow or
perfusion depends on
difference ( Pa – PA) &
called waterfall effect
West’s zones• Zone 3; Pv more than PA in
inspiration & expiration.
Flow depend on (Pa –Pv).
• Pulmonary blood flow is
constant in this region &
provide optimal condition
for gas exchange
#Swan-Ganz should float here posteriorly in supine position#
West’s zone
• Zone 4: the lung has
positive interstitial
pressure (PE, mitral
stenosis, pulmonary
edema)
• Flow depends on
difference between Pa and
Pi
What the 7 differences between apex and base of lungs?
• Alveoli at the top of the lungs;
– Larger at end-expiration
– Have lower ventilation
– Have lower perfusion
– Have higher V/Q ratio (3.3 vs 0.63)
– Higher pO2 (132 at apex, 89 at base)
– Lower pCO2 (28 at apex, 42 at base)
– Higher pH (7.51 vs 7.39)
Shunts
• True shunts is perfusion without ventilation (V/Q =
0)
• Refers to blood that enter arterial system without
passing ventilated areas of the lungs
• Effects;
– Reduce PaO2
– Increase A-a gradient
Venous admixture
• Amount of mixed venous blood has to be
added to pulmonary end capillary blood to
see drop in arterial PaO2
• Sometimes used interchangeably with shunts
2 main sources of blood contribute to venous
admixture
1. True shunts – 2 sources
– Bronchial vein
– Thebesian vein
2. Blood from alveoli with V/Q less than 1 e.g.
atelectasis, consolidated area, edema
Recollection
V/Q = 1
V/Q < 1V/Q > 1
Shunts vs Venous admixture
Shunt equation
Total flow = Qt
Shunted flow = Qs
Flow thro lungs = Qt - Qs
Shunt O2 content =
CvO2
Total O2 delivery = O2 delivery from ventilated lungs + O2 delivery from shunt
O2 flux/delivery = cardiac output x O2 content
Qt x Ca = (Qt – Qs) x CcO2 + (Qs x CvO2)
Qs = (CcO2 – CaO2)
Qt (CcO2 – CvO2
Total O2 delivery = O2 delivery from ventilated lungs + O2 delivery from shunt
Finally what we get…..
V/Q = ∞
V/Q = 0
What methods used to measure V/Q inequalities?
1. A-a oxygen gradient (normal 5-15 mmHg)
– Need alveolar gas equation PAO2= FiO2 x (760-47) –
(PaCO2/R) R = 0.8
– Increased in V/Q mismatch, shunting, diffusion
abnormalities
Measurement V/Q abnormalities (2)……
2. Shunt equation
– For low V/Q unit
3. Bohr equation
– For high V/Q unit
4. PaCO2 – ETCO2 difference
– ETCO2 normally 2-5 mmHg lower than PaCO2
– Increase in high alveolar deadspace (PE, low cardiac
output, venous air embolism)
Pulmonary blood flow & resistance
• Mixed venous blood frm RV main PA branches
of PA with bronchi/bronchioles central acinar
arterioles pulm capillaries small peripheral
acinar pulm veins pulm vein with
bronci/bronchioles 4 main pulm vein LA
Difference between pulmonary and systemic circuit
• Pulmonary is low pressure conduit (mean PAP 15 mmHg) (25/8)
• More pulsatile than systemic circuit
• Vessel much thinner
• Not all vessel are open at resting CO, increase flow recruitment & distension
Factors affecting pulmonary vessels
Pulmonary vascular resistance
1. Lung volume
– Both low and high lung volume with increase
PVR
2. Hypoxic pulmonary vasoconstriction
3. Metabolic substance
PVR = 80 x (MPAP –PCWP)/CO
Hypoxic pulmonary vasoconstriction
• Reflex vasoconstrictive effect of low alveolar PO2
• When alveoli are not ventilated HPV will
effectively shunt the blood away frm this alveoli to
a better ventilated unit
• Will reduce V/Q in equalities in the lungs &
improving oxygenation esp. in condition like LVF,
pulmonary edema
HPV…so what?
• Particular interest for anesthetist;
1. Effect of volatile agent on HPV
2. Role of HPV during one lung anaesthesia
Etiology of hypoxemia…..anyone?
1. Low inspired FiO2
2. Hypoventilation
3. Deadspace
4. Shunts
5. Increase diffusion capacity
Control of respiration
• Control of breathing is about supply and
demand
• Resp. system as supplier of oxygen &
provide the blood (road system) to the cells
(consumer) to perform aerobic metabolism
2 levels of control
Local control
• Location: alveoli, capillaries &
bronchioles
• Role; ensure gas & blood go to
appropriate part of lungs for
efficient gas exchange
• When: changes in CO2 and O2
• Mechanism: local adjustment to
blood flow (perfusion) & oxygen
delivery (alveolar ventilation) to
alveolar
Central control
• Location: RC located in medulla
oblongata & pons and modified by
sensory neuron (peripheral & CSF)
and higher centre
• Role: adjust the depth & rate of
ventilation
• When: during normal breathing &
during larger demand
• Mechanism: involuntary reflex via
sensory feedback and voluntary
control via RC
Local control of lung perfusion
Local control of alveolar ventilation
Local control tries to reduce V/Q imbalance………..
• Common value for V/Q ratio is 0.8• Local control aims at maintaining optimal V/Q
ratio
Central controlInvoluntary control
• Direct the depth & rate of
breathing via output from
respiratory centre
• Modified by influence from
receptors from the lungs and
CSF to ensure appropriate
levels of ventilation
Voluntary control
• Influenced indirectly from
cerebral cortex & affect the
output of respiratory centres
in the medulla oblongata
• Influential factors include
emotion, anticipation of
exertion & activities requiring
alteration to normal breathing.
Respiratory centers and breathing
• DRG is part of NTS which obtain info from
mechano & chemoreceptors, and project to
neuron of phrenic nerve which supply
diaphragm.
– Involves inspiratory process & timing
• VRG resides in nucleus ambiguus &
concerned with amplitude of respiration
Respiratory control reflexes
1. Sensors
– Peripheral & central chemoreceptors
– Muscle proprioceptors
– Lung, upper airway & pharyngeal receptors
2. Contoller
– Cortex (voluntary control)
– Brainstem (automatic control)
– Spinal cord (integration)
3. Effectors
– Muscle of respiration (via spinal respiratory
motor efferents
– Lungs, pharynxs, laryngx (via cranial nerve
respiratory motor efferent)
Hering-Breuer reflex
• Inflation & deflation reflexes occur during
forced breathing.
• With the cooperation of two reflexes, the
volume and stretch of the lungs is controlled
to avoid over expansion or over deflation
Respiratory functions
1. Non gas exchange functions
2. Gas exchange
Non gas exchange functions
1. Blood reservoir functions
– Contain ~ 450 mls of blood
– Increase PAP will increase pulmonary blood volume in
2 mechanisms
• Recruitment (more vessel open up)
• Distension (open vessel got bigger)
– “Central blood volume” defined as volume in the lungs
(450 mls) and heart (350 mls) = 800 mls
Intra-thoracic blood volume
2. Elimination of volatile substance
– Alcohol, acetones, volatile anesthetics
3. Blood filter – thrombi, microaggregates etc.
4. Metabolic activity
– Activation of AT 1 to AT 2 (maintaining sodium balance)
– Inactivation of noradrenaline, bradykinin, serotonin & prostatglandin
5. Immunological – IgA secretion into bronchial mucus
6. Miscellaneous
– Protein syntesis (collagen, elastin)
– Surfactant (DPPC) synthesis
– CHO metabolism (mucin & proteoglycan synthesis)