01.Anatomy and Physiology of Airway

Anatomi dan Fisiologi Anatomi dan Fisiologi Jalan Nafas Jalan Nafas

seimbang antara iman, seimbang antara iman, amal & ilmu.amal & ilmu. 11dhs wahyubroto.dhs wahyubroto.

The Body’s Need for The Body’s Need for OxygenOxygen

Living tissue must have oxygen to survive. Living tissue must have oxygen to survive. Brain death in humans occurs within 6 to 10 Brain death in humans occurs within 6 to 10

minutes of tissue anoxia. minutes of tissue anoxia. Rapid and safe airway control is paramount to the Rapid and safe airway control is paramount to the

successful management of critically ill and successful management of critically ill and

injured patients. injured patients.


Airway AnatomyAirway Anatomy

Upper airway structures include the:Upper airway structures include the:Mouth Mouth NoseNosePharyngPharyng Oropharyng Oropharyng

The lower airway structures include the:The lower airway structures include the:LaryngLaryngTracheaTrachea BronchiBronchiBronchiolesBronchioles AlveoliAlveoliLungsLungs

..


NoseNose Nasal cavityNasal cavity PharynxPharynx LarynxLarynx TracheaTrachea BronchiBronchi BronchiolesBronchioles Respiratory bronchiolesRespiratory bronchioles Alveolar ductsAlveolar ducts AlveoliAlveoli

conducting zone

• Transport, cleanse, warm and Transport, cleanse, warm and humidify incoming air humidify incoming air • Not involved in gas exchange Not involved in gas exchange • “ “Anatomical Dead Space”Anatomical Dead Space”

respiratory zoneFunction in gas Function in gas exchangeexchangeseimbang antara iman, seimbang antara iman,

amal & ilmu.amal & ilmu. 44dhs wahyubroto.dhs wahyubroto.

tongue

teeth

mandible

lips

oropharyng

hard palate

soft palate

MOUTH


NOSE

Concha superior

Concha medius

Concha inferior

sphenoid sinus

frontal sinus


PHARYNG:

- Nasopharyng

- Oropharyng (throat)

- Laryngopharyng


hard palate

tongue

soft palate

tonsilla palatina

epiglottis

vocal cordtrachea

concha

nasopharyng

uvula

oropharyng

laryngopharyng

UPPER

LOWER

eustachian opening

frontal sinus

sphenoid sinus


LARYNG (VOICE BOX)

- separates pharyng and trachea- cartilages, membrane, ligaments

- ♂ 45 mm long, Ø 35 mm

- ♀ 35 mm long, Ø 25 mm

FUNCTION- Patent airway

- To act as a switching

mechanism to route air and food into the proper channels- Voice production


Framework of the Larynx

thyrohyoid ligament



CRICOTHYROTOMY

- acute, life threatening upper airway obstruction- intubation not possible- conventional airway management not possible

SELLICK’S MANEUVRESELLICK’S MANEUVREUsed to prevent gastric distention Used to prevent gastric distention

TechniqueTechniqueApply slight pressure Apply slight pressure anteriorly over anteriorly over cricoid cartilagecricoid cartilageCloses off esophagusCloses off esophagusseimbang antara iman, seimbang antara iman,


Sellick’s Sellick’s ManueverManuever


The intrinsic muscles of the larynx attach to the arytenoid cartilage, and allow for movement of the vocal cords.

Movements of Movements of Vocal CordsVocal Cords


Glottis & Epiglottis

glottis

epiglottis


TRACHEA


TRACHEA VIEWED FROM ABOVE


primary bronchus

secondary bronchus

tertiary

bronchusbronchiole

terminalbronchiole

BRONCHIAL TREE

respiratory zone


…hair like projection called cilia line the primary bronchus to remove microbes and debris from the interior of the lungs…seimbang antara iman, seimbang antara iman,



Notice that the right is more vertical and fatter than the left which turns at a bit of an angle.seimbang antara iman, seimbang antara iman,


Respiratory bronchioles,Respiratory bronchioles,alveolar ducts, alveolar alveolar ducts, alveolar

sacssacs


Alveolar sacs Alveolar sacs look like look like clusters of clusters of grapesgrapes

The “individual The “individual grapes” are grapes” are alveolialveoli

Alveolar sacsAlveolar sacs AlveoliAlveoli


air-blood barrier


Respiratory PhysiologyRespiratory Physiology

BreathingBreathing

Pulmonary Ventilation Pulmonary Ventilation the movement of air into and out the movement of air into and out of the lungsof the lungs

Gas exchange occurs due to a pressure gradient (partial Gas exchange occurs due to a pressure gradient (partial pressures of gas)pressures of gas)

Two phasesTwo phases Inspiration: Breathing inInspiration: Breathing in

Active processActive process Expiration: Breathing outExpiration: Breathing out

Passive processPassive processseimbang antara iman, seimbang antara iman, amal & ilmu.amal & ilmu. 2525dhs wahyubroto.dhs wahyubroto.

Inspiration isInspiration is initiated by a stimulus in the initiated by a stimulus in the respiratory center of the brain. respiratory center of the brain. The signal is transmitted to the diaphragm via The signal is transmitted to the diaphragm via

the phrenic nerve. the phrenic nerve. The impulse causes the diaphragm to contract The impulse causes the diaphragm to contract

or flatten. or flatten. This causes intrapulmonic pressure to fall below This causes intrapulmonic pressure to fall below

atmospheric pressure and air is drawn into the atmospheric pressure and air is drawn into the lungs like a vacuum. lungs like a vacuum.

The ribs elevate and expand, the alveoli inflate, The ribs elevate and expand, the alveoli inflate, and oxygen and carbon dioxide diffuse across and oxygen and carbon dioxide diffuse across the membrane.the membrane.


Respiratory pressures are always described relative Respiratory pressures are always described relative to atmospheric pressureto atmospheric pressure

Boyle’s Law:Boyle’s Law: Volume of gas is inversely proportional to Volume of gas is inversely proportional to

pressure (if temperature constant)pressure (if temperature constant)

Volume= Volume= Constant Constant

PressurePressure So, when the volume of the container increases So, when the volume of the container increases

(expansion of the lungs), the pressure decreases(expansion of the lungs), the pressure decreases

Pressure in Thoracic Pressure in Thoracic CavityCavity


As the size of As the size of closed container closed container decreases, decreases, pressure inside pressure inside is increaseis increase

Same number Same number of molecules of molecules striking a striking a smaller smaller surface areasurface area

Boyle’s Law


Atmospheric Pressure (PAtmospheric Pressure (Patmatm)) - pressure exerted - pressure exerted

by the air surrounding the body. At sea level by the air surrounding the body. At sea level its equal to 760mmHg. its equal to 760mmHg.

Intrapulmonary Pressure (PIntrapulmonary Pressure (Palvalv)) - pressure exerted - pressure exerted

by the air within the alveoli. It rises and falls by the air within the alveoli. It rises and falls during inspiration and expiration, but it during inspiration and expiration, but it always equalizes with atmospheric pressure. always equalizes with atmospheric pressure.

Intrapleural Pressure (PIntrapleural Pressure (Pipip)) - pressure within the - pressure within the

pleural cavity. It is always lower than both pleural cavity. It is always lower than both atmospheric pressure and intrapulmonary atmospheric pressure and intrapulmonary pressure.pressure.

Pressure in Thoracic Pressure in Thoracic CavityCavity


pleura parietalis

pleura visceralis (attach to the lung)

pleural cavity

alveoli

PPatm

PPalvalv

Pip

• PPatm 760 mmHg• PPalv alv rises and falls during inspiration and expiration, but it always equalizes with atmospheric pressure• Pip < Patm or Palv


It is elastic and has a It is elastic and has a tendency to recoil tendency to recoil

Ribs want to expandRibs want to expand outward outward

Lungs want to collapseLungs want to collapse

Since the pressure in the plural space is Since the pressure in the plural space is lower than in the alveoli, the alveoli do not lower than in the alveoli, the alveoli do not collapse.collapse.

Lung Tissue


Alveolar pressure falls below Alveolar pressure falls below

atmospheric pressure.atmospheric pressure. Contraction of the diaphragm and Contraction of the diaphragm and

external intercostal muscles increases external intercostal muscles increases

the size of the thorax (thereby the size of the thorax (thereby

decreasing the intra-pleural pressure) decreasing the intra-pleural pressure)

and the lungs expand.and the lungs expand. Intra-pleural (thoracic) pressure is Intra-pleural (thoracic) pressure is

always 4 mmHg less than the always 4 mmHg less than the

atmospheric pressure just before atmospheric pressure just before

inhalation (756 mm Hg)inhalation (756 mm Hg)

Inspiration


Expansion of the lungs decreased Expansion of the lungs decreased

alveolar pressure to 758 mm Hgalveolar pressure to 758 mm Hg Atmospheric pressure is 760 mm HgAtmospheric pressure is 760 mm Hg Air flows into the lungs because of this Air flows into the lungs because of this

pressure gradientpressure gradient Inspiration causes intra-pleural Inspiration causes intra-pleural

pressure to decrease to 754 mm Hgpressure to decrease to 754 mm Hg

Inspiration




Air is forced out Air is forced out of the lungs as of the lungs as the muscles the muscles relax reducing relax reducing the volume of the volume of the chest cavity the chest cavity and increasing and increasing the pressurethe pressure

EXPIRATION


Occurs when alveolar pressure is higher Occurs when alveolar pressure is higher than atmospheric pressurethan atmospheric pressure

762 mm Hg762 mm Hg Elastic recoil of the chest wall and lungs Elastic recoil of the chest wall and lungs

(main force) (main force) and the relaxation of the and the relaxation of the diaphragm increases intra-pleural and diaphragm increases intra-pleural and alveolar pressure and decreases lung alveolar pressure and decreases lung volumevolume

Air moves outAir moves out Quiet breathing does not take any effort (no Quiet breathing does not take any effort (no

muscles are being contracted)muscles are being contracted)

EXPIRATION




3 Major Factors3 Major Factors Alveolar surface tensionAlveolar surface tension ComplianceCompliance Airway resistanceAirway resistance

Pulmonary VentilationPulmonary Ventilation


Surface tension causes the alveoli to Surface tension causes the alveoli to assume the smallest diameterassume the smallest diameter Major component of lung elastic recoilMajor component of lung elastic recoil

Surfactant is a phospholipid produced by Surfactant is a phospholipid produced by Type II cells in alveolar wallsType II cells in alveolar walls Alters surface tension below the surface Alters surface tension below the surface

tension of pure watertension of pure water Prevents alveolar collapse following Prevents alveolar collapse following

expirationexpiration If surface tension is too high, alveoli collapse If surface tension is too high, alveoli collapse

and great effort is needed to reopen themand great effort is needed to reopen them

Alveolar surface tensionAlveolar surface tension


ComplianceComplianceRatio of volume changes caused by pressure changes Ratio of volume changes caused by pressure changes V/V/PP

• Lung ComplianceLung Compliance

• Thoracic wall ComplianceThoracic wall Compliance

Low compliance To get desired volume there must be higher pressureTo get desired volume there must be higher pressure

High compliance

Low pressure will give high tidal volume Low pressure will give high tidal volume


stiff Elastis

LOW COMPLIANCE

HIGH COMPLIANCE

BALLOON

COMPLIANCE COMPLIANCE (COMPL)(COMPL)


P-V P-V LOOPLOOP

15

30

250

500

0

P

Vol

500

500

250

250

15

30

15

30

LOW COMPLIANCE

HIGH COMPLIANC

E

NORMAL

PEEP 5INSPIRATION

EKSPIRATION

Spontaneus breathing


The walls of the respiratory passageways The walls of the respiratory passageways have resistance to the normal flow of air have resistance to the normal flow of air into the lungsinto the lungs

The smaller the diameter, the greater the The smaller the diameter, the greater the resistanceresistance

Any condition that obstructs the air Any condition that obstructs the air passageway increases resistance, and more passageway increases resistance, and more pressure is need to force air throughpressure is need to force air through AsthmaAsthma Inflammation due to infectionInflammation due to infection EmphysemaEmphysema

ResistanceResistance


FLOW = PRESSURE

RESISTANCE

BRONCHOCONSTRICTION: HISTAMIN

OBSTRUCTION: MUCUS / SECRET

AIRWAY RESISTANCE (RAW)


FLOW = PRESSURE

RESISTANCE

BRONCHOSPASM TUMOUR / SECRET

TOO SMALL ETT

COLLAPSE/ATELECTASIS

AIRWAY RESISTANCE (RAW)


Partial PressurePartial Pressure Dalton’s LawDalton’s Law: each gas in a mixture of : each gas in a mixture of

gases exerts its own pressure as if all gases exerts its own pressure as if all other gases were not presentother gases were not present Air 78% nitrogen, 21% oxygen, 1% other Air 78% nitrogen, 21% oxygen, 1% other

(CO(CO22)) Partial pressure of a gas is the pressure Partial pressure of a gas is the pressure

of an individual gas in a mixture.of an individual gas in a mixture. PO2 21% X 760 = 159.6 mm HgPO2 21% X 760 = 159.6 mm Hg Total pressure is adding all the partial Total pressure is adding all the partial

pressurespressuresseimbang antara iman, seimbang antara iman, amal & ilmu.amal & ilmu. 4848dhs wahyubroto.dhs wahyubroto.

Exchange of OExchange of O22 and CO and CO22

OO22 and CO and CO22 Diffuse from areas of higher Diffuse from areas of higher partial pressures to areas of lower partial partial pressures to areas of lower partial pressurepressure

Results in exchange of OResults in exchange of O22 and CO and CO2 2 in the in the alveolialveoli Alveoli: PAlveoli: PAAOO22=105 =105 mm Hg, mm Hg, PCO2=40PCO2=40 mm Hgmm Hg

Capillaries: PCapillaries: PvvOO22=40 =40 mm Hg, mm Hg, PPVVCOCO2 2 =45 =45 mm Hgmm Hg

Pulmonary veinPulmonary vein::PPAAOO22=100 PCO2=40=100 PCO2=40 mm Hgmm Hgseimbang antara iman, seimbang antara iman, amal & ilmu.amal & ilmu. 4949dhs wahyubroto.dhs wahyubroto.

O2 and CO2 Diffuse from areas of higher partial pressures to areas of lower partial pressure

Exchange of O2 and Exchange of O2 and CO2CO2



RELATIONSHIP BETWEEN VENTILATION (V) AND PERFUSION (Q)

Normal V/Q = 1

V/Q > 1

alveolar dead spaceV/Q < 1

shunt



TERIMA KASIH


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01.Anatomy and Physiology of Airway