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Respiratory Physiology 2010
1
Respiratory Physiology 2010 Schedule
Lecture/Lab Day Date Time
Overview of Gas Exchange Friday Oct/7/2010 9:10-10:00
Gas Volumes & Ventilation Friday Oct/8/2010 10:10 –11:00
Mechanisms of Breathing Monday Oct/8/2010 11:10-Noon
Howard A. Rockman, M.D.
Lectures modified from Jo Rae Wright, Ph.D.
Respiratory Physiology 2010
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Contents
Section Page
Symbols used in Respiratory Physiology 5
General abbreviations 5
Modifiers 5
Examples 6
Overview of Gas Exchange 7
Introduction 8
Major Functions of the Respiratory System 8
Respiration 8
Anatomy of the Respiratory System 9
Gross Anatomy 9
Airways 10
Alveolar-Capillary Unit 11
A Simple Model Of The Respiratory System 11
Lung Volumes and Capacities 12
Definitions of Standard Lung Volumes and Capacities 13
Indirect Measurement of Lung Volumes 14
Body Plethysmograph 14
Composition of Environmental and Alveolar Gas 15
Partial Pressure of Gases 15
Partial Pressure of Gases in Gases 15
Partial Pressures of Alveolar Gases 16
Non-Respiratory Functions of the Lung 17
Diffusion of Gases 19
Overview 19
Gases Diffuse from a Region of High Partial Pressure to a Region of
Low Partial Pressure 20
Diffusion of Gases in Gases 20
Diffusion of Gases in Liquids 20
Diffusion of Gases Across the Alveolar-Capillary Membrane 20
Fick’s Law for Diffusion 21
Transfer of O2 and CO2 between Alveolus and Capillary 21
Measurement of Diffusion Capacity 22
Single-Breath CO Method 22
Effects Of Exercise On Diffusing Capacity 22
Examples of Diseases that Affect Diffusion of Gases 23
Diseases Associated with Decrease Surface Area for Diffusion 23
Diseases that Affect “t” (“Thickness”) 23
Respiratory Physiology 2010
3
Contents (continued)
Section Page
Lung Mechanics 24
Overview 24
Pressures of the Respiratory System 25
Units of Pressure Measurements 25
Intrapleural Pressure 25
Transmural Pressure 26
Recoil of the Lungs 27
Collagen And Elastin Fibers 27
Surface Tension 27
Pressure-volume Curves of the Lung 28
Effects of Surfactant on Alveolar Stability 30
Lung Compliance & Disease 32
Elastic Recoil of the Chest Wall 32
Relaxation Pressure Volume Curve of The Respiratory System
(Lung + Chest Wall) 32
Airway Resistance 34
Factors that Influence Airway Resistance 34
Airway Diameter 34
Lung Volume 34
Elastic Recoil 35
Airway Smooth Muscle Tone 35
Measurement of Airway Resistance 35
Forced Expiratory Vital Capacity Curve 35
Dynamic Airway Compression 35-37
Respiratory Physiology 2010
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List of Figures
Figure Page
Fig. 1.1 Schematic Representation Of External and Internal Respiration 8
Fig. 1.2 Model of the Airways 10
Fig. 1.3 Simplified Model of the Respiratory System 12
Fig. 1.4 Typical Volumes and Flows 12
Fig. 1.5 Spirometric Measurement of Lung Volumes and Capacities 13
Fig. 1.6 The approximate changes in partial pressure of O2 and CO2 in
alveolar gas 16
Fig. 1.7 Pulmonary Function test 18
Fig. 2.1 Time course for Transfer of Gas Between the Alveolus and the
Capillary Blood 21
Fig. 3.1 Transpulmonary Pressures in the Respiratory System 26
Fig. 3.2 Synthesis of Surfactant 28
Fig. 3.3 Pressure-volume Curve of the Lung 29
Fig. 3.4 Volume vs. inflation pressure during lung inflation with air and saline 29
Fig. 3.5 Laplace Law 31
Fig. 3.6 Deflation Pressure Curves of the “Normal” and Diseased Lung 33
Fig. 3.7 Intraorgan and Transorgan Pressure During Inspiration and End
of Expiration 33
Fig. 3.8 Forced Expiratory Vital Capacity Curve 36
Fig. 3.9 Dynamic Airway Compression 37
Respiratory Physiology 2010
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Symbols used in Respiratory Physiology
These abbreviations are used not only in respiratory physiology but also in virtually all systems.
GENERAL ABBREVIATIONS
C Compliance
c Concentration, content
D Diffusing capacity
f Respiratory frequency
F Fraction concentration (dry gas)
P Gas pressure
R Resistance
R Respiratory exchange ratio
Q Volume of blood
V Gas volume
Q Volume of blood per unit time (blood flow)
V Gas volume per unit time (gas flow)
MODIFIERS
A Alveolar gas
B Barometric
D Dead space gas
E Expired gas
I Inspired gas
T Tidal gas
aw Airway
cw Chest wall
et End tidal
es Esophageal
pl Intrapleural
L Lung
rs Respiratory system
cw Transchestwall
L Transpulmonary
rs Transrespiratory system
Respiratory Physiology 2010
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a Arterial blood
c Capillary blood
t Tissue
Mean value
Time derivative
EXAMPLES
PAO2 Partial pressure of oxygen in alveolar gas
PaO2 Partial pressure of oxygen in arterial blood
FECO2 Fraction of CO2 in dried, expired gas
PETCO2 Partial pressure of carbon dioxide in end tidal gas
VO2 Oxygen consumption per unit time
VA/Q Ventilation/perfusion ratio
Respiratory Physiology 2010
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Overview of Gas Exchange
Objectives
• Relate the structural organization of the respiratory system to its function.
• Describe the functional importance of the intrapleural fluid and the parietal and
visceral pleura.
• Know the structural and functional features that distinguish the respiratory zone of the
airways from the conducting zone.
• Define and describe the alveolar-capillary unit.
• Know the major functions of type I cells, type II cells, and alveolar macrophages.
• Know the symbols that are commonly used in respiratory physiology.
• Know the definitions of fractional concentration (of a dry gas) and partial pressure of
a gas.
• Know the normal values for partial pressure of oxygen and carbon dioxide in arterial
and mixed venous blood.
Introduction The major functions of the respiratory system can be divided into two categories: respiratory
and non-respiratory. The first function, which will be emphasized in this course, is to carry out gas
exchange. Metabolizing tissues utilize oxygen and produce carbon dioxide. The respiratory system
must obtain oxygen from the environment and must eliminate CO2 that is produced by cellular
metabolism. These processes must be coordinated so that the demand for oxygen is met and so that
the CO2 that is produced is eliminated. It should be intuitive to most people that cells cannot live
without an adequate supply of oxygen. It may not be intuitive, however, that failure to eliminate CO2 adequately can also be harmful because changes in CO2 levels affect acid-base balance in the body.
The respiratory system, which includes the lungs, airways, the portion of the nervous system
involved in respiratory control, the chest wall, and muscles, is well designed to carry out gas
exchange in an expeditious manner.
The respiratory system is also involved in non-respiratory functions. It participates in
maintaining acid-base balance in the body since increases in CO2 concentrations in the body lead to
increased hydrogen ion concentrations. The lungs also metabolize naturally occurring compounds
such as angiotensin I, some prostaglandins, and norepinephrine. The lungs are also responsible for
protecting the body from inhaled particles.
Respiratory Physiology 2010
8
Figure 1.1: Schematic Representation Of External and Internal Respiration
Oxygen consumption is abbreviated ( 2VO ) and carbon dioxide production is abbreviated
( 2V
CO ). The dot ( ) indicates a time derivative. Thus, the units for 2VO and are ml/min.
Major Functions of the Respiratory System
Respiration
The term respiration encompasses all of the processes that are involved with supplying the
tissues with oxygen and removing the carbon dioxide that is produced during cellular metabolism.
“External” Respiration
“External” respiration is the movement of oxygen from the atmosphere to the cells of the body
and the movement of carbon dioxide from the cells to the atmosphere. The exchange of carbon
dioxide and oxygen takes place in the lungs. Upon command from the central nervous system, the
inspiratory muscles contract, the chest wall expands, and fresh air flows into the lungs.
Respiratory Physiology 2010
9
Simultaneously, venous blood, from which oxygen has been removed by metabolizing tissues and to
which carbon dioxide has been added, flows from the tissues to the lungs. In the pulmonary
capillaries, oxygen diffuses into the blood and carbon dioxide diffuses out. This blood which now
has a high concentration of oxygen and a low concentration of carbon dioxide flows to the tissues.
When the muscles of the respiratory system finally relax, expiration occurs and the gas that is
enriched in carbon dioxide is expelled from the lungs.
“Internal” Respiration
“Internal” respiration is the utilization of oxygen by the cells of the body to produce energy and
the by-product of metabolism, carbon dioxide. A general formula for this process is
O2 + Food CO2 + H2O + Energy (ATP) (1.1)
Because the chemical composition of different foodstuffs differs (i.e., carbohydrates, fat, and
proteins), the amount of oxygen that is utilized and the amount of carbon dioxide that is produced
when they are metabolized differs.
Anatomy of the Respiratory System
Gross Anatomy
The right and left lungs are housed in the thoracic cavity. The right lung has three lobes and the
left lung has two. The right and left lungs are separated by the mediastinum. The thoracic cavity is
lined by the parietal pleura and the lungs are covered by the visceral pleura. Between the two pleurae
is a thin film of fluid, called the intrapleural fluid. The pleural fluid functions as a lubricant and
serves to functionally connect the lungs and chest wall. Inspiration begins when the diaphragm and
the muscles of the chest wall contract. Contraction of the diaphragm causes it to descend and
contraction of the intercostal muscles of the chest wall raises the ribs. The muscles contract in
response to neural impulses from the brainstem. As a result of the muscle contraction, the thoracic
cavity is enlarged. Because the lungs are functionally connected to the chest wall by the visceral and
parietal pleura (which cover the lungs and the chest wall, respectively), the lungs are also expanded.
This increase in volume results in reduction of the pressure of the gases in the terminal airspaces
(alveolar ducts and alveoli, see below). Air is like water in that it flows from a region of high total
pressure to a region of low total pressure. This type of airflow is called bulk flow. When the pressure
in the alveoli (PA) becomes less than the pressure at the mouth, which is ordinarily atmospheric
pressure (PB), air flows in until PA = PB.
Expiration occurs when the muscles of inspiration relax. The lung is elastic and will return
passively to its pre-inspiratory volume. This reduction in volume raises the pressure in the lung and
gas will therefore flow out of the lung.
Respiratory Physiology 2010
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Airways
Upon inhalation, air moves into the respiratory system through the nose and mouth. The air is
heated, warmed to body temperature, and humidified as it enters the airways. The airways are a
series of branching tubes that become narrower, shorter, and increase in number from the single tube
that is the trachea to the several hundred thousand bronchioles. The airways are not rigid tubes, but
are flexible. All together, the airways divide a total of 23 times. The airways are divided into two
parts: conducting zone and respiratory zone.
Figure 1.2: Model of the Airways
CONDUCTING ZONE includes all of the branchings down to and including the terminal bronchioles.
The function of the conducting zone is to lead inspired gas to the gas exchanging regions. The
conducting zone is ideally suited to its function because it has a small diameter, a small surface area,
and a small total volume (about 150 ml). These factors minimize the volume of inspired air that is
“wasted” or that does not participate in gas exchange. Since no gas exchange occurs in the
conducting zone, it is often called the anatomical dead space.
RESPIRATORY ZONE is the region of the lung where gas exchange occurs. The respiratory bronchioles
(generations 17-19) have a few alveoli budding off their walls. Alveoli are small sac-like structures
with very thin walls. Generations 20-22 are called alveolar ducts and they are completely lined with
alveoli. The branching terminates with the blind alveolar sacs. The volume of the respiratory zone is
much larger than the conducting zone (about 3000 ml.)
Respiratory Physiology 2010
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Alveolar-Capillary Unit
Gas exchange is a two way street involving uptake of oxygen and elimination of carbon dioxide.
The site of gas exchange is the alveolar-capillary unit. The 300 million alveoli are virtually
surrounded by pulmonary capillaries. The resulting area of contact between gas and blood is about
the size of a tennis court. The distance that gas has to diffuse is very short. The alveolar capillary
membrane is about 0.2 microns thick or about 1/50 the thickness of a piece of airmail stationery. The
large surface area and short distance for diffusion make the alveolar-capillary unit ideally suited for
gas exchange.
Type I Cells
Type I cells line about 90% of the surface area of the alveoli. They are very thin squamous
epithelial cells and are considered to be the site of gas exchange.
Type II Cells
Type II cells are interspersed among the type I cells. Type II cells synthesize, secrete and
metabolize alveolar surfactant. Surfactant is a lipid-rich substance that lines the alveoli and helps
keep lungs from collapsing. This subject will be discussed in detail later.
Alveolar Macrophages
Alveolar macrophages are the third type of cell type found in the alveoli. Macrophages
phagocytose or engulf inspired particles such as bacteria. The cells are mobile and are attracted to
areas of infection or trauma.
A Simple Model Of The Respiratory System
The diagram shown in Figure 1.3 is a convenient and simple way to view the respiratory system.
The many branching bronchi that make up the conducting airways are represented by a single tube
called the anatomical dead space or conducting zone. The multiple alveolar-capillary units, which
are the sites of gas exchange, are represented by a half-circle (the respiratory zone) in close
approximation to a tube through which blood flows. At the end of expiration, the volume of gas in
the conducting zone is approximately 150 ml. The volume of gas in the respiratory zone is
approximately 3000 ml.
The methods for measuring these volumes, which can change dramatically in diseases, will be
discussed in laboratory. The alveolar gas in the respiratory zone is in contact with approximately 70
ml of pulmonary capillary blood at any given moment.
With each inspiration, approximately 500 ml of gas enters the lungs. The volume of air entering
the nose or mouth per breath is called the tidal volume. (NOTE: The “normal” values traditionally
provided in physiology text books generally apply to a 70 kg adult male. “Normal” lung volumes are
usually about 20-25% lower in females. The values are only approximations and will, of course, vary
from patient to patient.)
Respiratory Physiology 2010
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In Figure 1.4, the volumes shown on the left side of the diagram below are static values; typical
flows and how they are calculated are shown on the right hand side of the diagram of lung volumes
is an important diagnostic tool since pathological states often alter both lung volumes and their
relationships to one another. There are many accepted protocols for measurement of lung volumes.
The methods can be subdivided into two categories: direct and indirect. A few of the most
commonly used methods are discussed below.
Figure 1.3: Simplified Model of the Respiratory System
Figure 1.4: Typical Volumes and Flows
Lung Volumes & Capacities
There are two types of conditions under which volumes are measured: dynamic and static.
Dynamic volumes refer to measurements made when volumes are changing, i.e., during gas flow.
Static volumes can be measured between two points where there is no flow, for example before and
after inspiration. We will discuss static lung volumes first.
2500 ml
Respiratory Physiology 2010
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There are four standard lung volumes. There are also four standard lung capacities, which consist
of a combination of two or more volumes. Accepted “normal” values are included below. Note:
“Normal” values may vary from text to text or hospital to hospital.
Definitions of Standard Lung Volumes and Capacities
• Tidal volume (VT): volume of air inhaled or exhaled with each breath (in adult
males about 500ml; in general, lung volumes in females are usually about 20-
25% less).
• Inspiratory reserve volume (IRV): Volume of air that can be inspired after a
normal inspiration (about 3.0 L in males).
• Expiratory reserve volume (ERV): Maximal volume of air that can be expired
from resting expiratory level (about 1.0 L in males).
• Residual volume (RV): Volume of air in lungs at end of maximal expiration
(about 1.5 L males)
• Inspiratory capacity (IC=VT+IRV): Maximal volume of air that can be inspired
from resting expiratory level (about 3.5 L in males)
• Functional residual capacity: (FRC=RV+ERV): Volume of air in lungs at end
of a normal expiration. (approximately 2.5 L in males)
• Vital capacity (VC=ERV+VT+IRV): Volume of air that can be expired after
maximal inspiration (approximately 4.5 L)
• Total lung capacity (TLC=RV+ERV+VT+IRV): Volume of air in lungs at end
of maximal inspiration (about 6 L).
Figure 1.5: Spirometric Measurement of Lung Volumes and Capacities
IRV
ERV
Respiratory Physiology 2010
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A spirometer is a simple volume recorder. It consists of two metal cans, one being larger than
the other. The larger can is filled with water and sits right-side up. The smaller can is immersed
upside down. A pulley is attached to the smaller can so that when the can moves up and down its
excursions are recorded on paper. A tube into which the patient breathes is in contact with the air in
the upside down can. So, when air moves into or out of the can, the can moves up and down and the
pen records this movement. (See diagram above.)
To determine lung volumes, the subject is usually seated and breathes quietly into the spirometer.
Volume is plotted on the y-axis and time on the x-axis. Note: although time is recorded in these
measurements, it is not relevant. Upon inspiration the pen moves up; upon expiration it moves
down. An idealized recording with the standard lung volumes and capacities and their definitions is
shown above in Figure 4.1.
The fact that the volume that a given amount of gas occupies varies with the temperature, and
pressure of the gas is a concept that is taught in introductory physics. This concept is important in
the measurement of lung volumes. As explained above, lung volumes are often measured with a
spirometer. The gas in the spirometer is at room (or ambient) temperature and pressure and is
saturated (ATPS). In order to calculate the actual volume that the gas occupied in the lungs, its
volume must be converted to body temperature, pressure and saturated with water vapor (BTPS).
The ideal gas law can be used to convert measurement made at ATPS to BTPS. Lung volumes are
reprinted at BTPS.
Indirect Measurement of Lung Volumes
Although the spirometer is a useful tool for measuring lung volumes it has some disadvantages.
First it can only measure the lung volumes that the subject can exchange with the gas in the
spirometer. Second, the patient must be awake and cooperative. The “indirect” methods of body
plethysmography is often used to determine functional residual capacity. The residual volume and
total lung capacity can then be calculated from the functional residual capacity measurement and the
volumes measured by spirometry.
Body Plethysmograph
The body plethysmograph is an air tight box that looks like a phone booth. The patient is hooked
up to an apparatus that measures the pressure at the patient’s airways (The pressure at the mouth
(airway pressure) will be equal to the pressure in the alveoli if there is no airflow). The patient’s
airflow is monitored by a pneumotachograph. The respiratory therapist can briefly block airflow at
the end of an expiration and measure the pressure at that time (P1). The patient is then instructed to
make an inspiratory effort against the closed airway and the pressure at the end of the inspiratory
effort is measured (P2). As a result of this inspiratory effort, the patient’s lungs expand (increase in
volume) which results in compression of the gas in the airtight chamber. Therefore, the pressure of
the gas in the chamber will rise and this change in box air pressure is recorded. The chamber is
calibrated so that a known change in box pressure is produced by a known change in volume (∆V).
Therefore the lung volume (V) can be estimated from the change in the volume of gas in the box
according to the equation: P1V = P2 (V + ∆V). One advantage of the method of plethysmography is
that any trapped gas that is not in communication with the airways will still be included in the
measurement.
Respiratory Physiology 2010
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Composition of Environmental and Alveolar Gas
In order to perform its function of providing cells with oxygen and removing the carbon dioxide
that is produced, the pulmonary system must increase the amount of oxygen in the alveoli above that
found in the mixed venous blood. It must also lower the carbon dioxide in the alveoli below that of
mixed venous blood. Gases move by diffusion from regions of high partial pressure to regions of
low partial pressure.
Partial Pressure of Gases
The partial pressure of a gas is designated by the symbol “P” followed by a subscript designating
the gas in question. Thus, PO2 is the partial pressure of oxygen.
Partial Pressure of Gases in Gases
Gas molecules behave like individual particles that are in a constant state of motion. When the
particles collide with one another or the sides of the container they exert a pressure. The pressure
exerted will depend on the number of collisions. The more particles there are, the more collisions
there will be and therefore, the pressure exerted by the particles will be higher. At a given
temperature, the pressure of a gas is a measure of its concentration.
At sea level, the pressure exerted by gases found in the atmosphere is sufficient to support a
column of mercury 760 mm high (in average weather) in a sealed tube placed in a dish of mercury
open to the atmosphere. Therefore, a pressure of 1 atmosphere = 760 mm Hg. A container of pure
oxygen (or any other gas) at sea level will have a partial pressure of 760 mm Hg (i.e., PO2= 760 mm
Hg).
If we have a mixture of gases, the pressure exerted by each is the same as it would be if that gas
alone occupied the entire container (this is Dalton’s law). One way to think about this concept is that
the gas molecules are far enough apart that they do not interfere with each other so that they behave
as if there were no other gases around. To calculate the partial pressure of a gas “X”, PX = PB x FX,,
where PB is the barometric pressure (at sea level PB = 760 mm Hg), and FX is the fractional
concentration of gas X. Fractional concentration is simply the fraction of the dry gas molecules
which are gas X (i.e., FO2 = PO2/(PB-PH2O)). For simplicities sake, respiratory physiologists and
physicians generally assume that room air is always dry. Since 21% of dry room air is oxygen, the
PO2 of room air = FO2 x PB = 0.21 X 760mm Hg = 160 mm Hg. The concentration of carbon
dioxide in room air is so low (0.04%), it is generally considered to be zero. Once gas is inhaled it
becomes saturated with water vapor and warmed to body temperature. Even on a very cold, dry day
all of the inspired air will become saturated with water vapor and warmed to 37oC. At 37oC, the
partial pressure of water (PH2O)= 47 mm Hg. Recall, the PO2 of dry room air = FO2 x PB = 0.21 X
760mm Hg = 160 mm Hg. When this gas is warmed to 37oC, and becomes humidified as it passes
through the nasal passages, water vaporizes into the gas until the PH2O = 47 mm Hg. What this
means is that only 760 - 47 mm Hg or 713 mm Hg is available for other gases besides water.
Therefore, the PO2 of tracheal or inspired gas (abbreviated PIO2) = (760-47 mm Hg) X 0.21 = 150
mmHg.
Respiratory Physiology 2010
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Partial Pressures of Alveolar Gases
Obviously the partial pressure of oxygen and carbon dioxide will vary during the respiratory
cycle. As fresh air, which is rich in oxygen and poor in carbon dioxide, enters the respiratory zone
during inspiration, the alveolar partial pressure of oxygen will rise and the alveolar partial pressure
of carbon dioxide will fall. As gas exchange occurs, the alveolar partial pressure of carbon dioxide
will rise and the alveolar partial pressure of oxygen will fall. Because these fluctuations are small (a
few mm Hg), they are generally ignored and only mean values PO2 and PCO2 are considered.
Figure 1.6: The approximate changes in partial pressure of O2 and CO2in alveolar gas.
The mean PO2 and PCO2(approximately 100 and 40 mm Hg, respectively) is
indicated by the horizontal line.
(Note: the fluctuations are small since 350 ml of gas entering the respiratory zone
with each breath is small compared to the 3000 ml there at the end of expiration).
Normal values for mean alveolar partial pressures are PO2 = 100 mm Hg and PCO2=
40 mm Hg. You should memorize these values.
Another important concept that must be conveyed is that at sea level and when there is no flow of
gas, the sum of all partial pressures of gases must be equal to barometric pressure which is close to
760 mmHg. For example, the partial pressures of gases in dry air are: PO2 = 160 mm Hg; PN2= 600
mmHg; PCO2 = 0 mm Hg. The partial pressure of gases in alveolar gas are: PO2 = 100 mm Hg;
PN2= 573 mm Hg; PCO2= 40 mm Hg; PH2O = 47 mm Hg. In both cases when there is no flow
Ptotal = 760 mm Hg.
Respiratory Physiology 2010
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The total and partial pressure of respiratory gases in “ideal” alveolar gas and blood (at sea level) are
shown below.
Ambient air Moist tracheal Alveolar gas Systemic Mixed venous
(dry) air (R = 0.80) arterial blood blood
PO2 160 150 100 100 40
PCO2 0 0 40 40 46
PH2O, 37°C 0 47 47 47 47
PN2 600 563 573 † 573 573
P total 760 760 760 760 706 ‡
† PN2 is increased in alveolar gas because R < 1 normally
‡ Ptotal in venous blood is reduced because PO2 has decreased more than PCO2 has increased.
Non-Respiratory Functions of the Lung
Note: This topic will not be covered in lecture. This information is included for completeness.
The lung carries out several non-respiratory functions. Several vasoactive substances are
metabolized in the lung including prostaglandins. Approximately 30% of the norepinephrine in
mixed venous blood is removed by the lung. On the other hand epinephrine and isoproterenol are not
metabolized by the lung. It may be worthwhile to consider that the response of a patient to an
injection of norepinephrine would be quite different if it were injected through an arterial or venous
catheter.
The lung also plays an important role in host defense against infection. We inspire all sorts of
noxious particles and gases, as well as bacteria. Some of the material is trapped in the small airways
and is eventually removed from the lung by the action of the cilia of the airway epithelial cells. In
addition, the alveolar macrophage can engulf and inactivate invading foreign particles and bacteria.
This is only a partial list of the non-respiratory functions of the lung. This subject is a relatively
new one and it is likely that as our ability to isolate and purify the 40 some different cell types found
in the lung improves, our understanding of their metabolic functions will also improve.
Respiratory Physiology 2010
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Figure 1.7: Sample Pulmonary Function Test
Respiratory Physiology 2010
19
Diffusion of Gases Objectives
• Know the factors that determine rates of diffusion of gases in gases and gases in liquids.
• Know how diffusion differs from bulk flow.
• Be able to state Fick’s law for diffusion.
• Describe the rate of diffusion of oxygen across the alveolar capillary membrane.
• Describe the rate of diffusion of carbon dioxide across the alveolar capillary membrane.
• Know why CO is most often used to measure diffusing capacity.
• Describe the effects of exercise on diffusing capacity.
• Know that it is very rare that impaired diffusion exists as a single physiological abnormality.
The process that causes the thickening of the membrane or the decrease in surface area almost
always leads to uneven ventilation, uneven capillary blood flow and therefore, uneven matching of
gas and blood (ventilation/perfusion).
Overview
The previous chapter dealt with how gas is moved into and out of the lungs and the volumes that
are normally involved. The next subject deals with the movement of gas from the alveolar air into
the blood and from the blood into alveolar air. The process of movement is a passive one that is
governed by the laws of diffusion. In order to understand the subject of diffusion of gases, we will
discuss some of the physical laws that govern the diffusion of gases, consider the properties of the
blood-gas barrier across which gas must diffuse, talk about some limitations to diffusion and
perfusion, and finally discuss the measurement of diffusing capacity.
Gases Diffuse from a Region of High Partial Pressure to a Region of Low Partial Pressure
Because of their random motion, gases will distribute themselves throughout a given space until
the partial pressure is the same everywhere. This process is diffusion and differs from movement of
gas by bulk flow. Bulk flow is mass movement of gases as a result of differences in their total
pressure. Molecules of different gases move from a region of high total pressure gradient to a region
of low total pressure. During diffusion, each individual gas moves according to its own partial
pressure gradient.
Respiratory Physiology 2010
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Diffusion of Gases in Gases
The rate of diffusion of gases in a gaseous phase is dependent on the size of the gas molecules.
Small molecules diffuse faster than large ones. The rates are proportional to the inverse of the square
roots of their molecular weights (Graham’s law). Thus, in gases, oxygen diffuses more rapidly than
does carbon dioxide. However, in the alveoli, it only takes a fraction of a second for newly inspired
gas to come into equilibrium with alveolar gas. Therefore, this difference in diffusion rates of
oxygen and carbon dioxide in gas is rarely a limiting factor. The equation below compares the rate
for transfer of CO2 and O2 through a barrier with pressure kept equal on both sides so that there is
no bulk flow.
Rate of transfer of CO2 MWO2
Rate of transfer of O2 MWCO2
32
44
5.66
6.63= = =
(2.2)
Diffusion of Gases in Liquids
Pulmonary physiologists must also be concerned about the rate at which gases diffuse in liquids,
such as blood or tissues. Henry’s law states that at any given temperature, the equilibrium
concentration of a gas that does not combine chemically with the liquid is directly proportional to the
partial pressure of the gas to which the liquid is exposed and directly proportional to the solubility of
the gas in the liquid. In water the solubility of CO2 at 37°C is (0.07 ml/100 ml plasma)/mm Hg. The
solubility of O2 is only about (0.003 ml/100 ml plasma)/mmHg. This difference of about 23 fold far
outweighs the 1.17-fold advantage of O2 over CO2 from molecular weights.
Rate
Solubility
MWα
(2.3)
Rate CO2
Rate O2
23
1=
(2.4)
However, the driving pressure for CO2 diffusion is lower (46-40 mm Hg = 6 mm Hg) than is the
driving pressure for oxygen diffusion (100-40 mm Hg = 60 mm Hg). Thus, even though the
solubility of carbon dioxide is much greater than the solubility of oxygen, the net result is that CO2
reaches equilibrium only slightly before O2 reaches equilibrium. Both oxygen and carbon dioxide
are very soluble in lipids, therefore, the barrier posed by cell membranes is small compared to the
barrier of aqueous layer to oxygen diffusion.
Diffusion of Gases Across the Alveolar-Capillary Membrane
In order to reach the blood, oxygen must diffuse through several layers including the alveolar
surfactant layer, the liquid beneath the surfactant, the alveolar epithelium, the capillary endothelium,
a layer of plasma in the pulmonary blood, the erythrocyte membrane, and finally through the
intracellular fluid of the erythrocyte. Carbon dioxide follows the reverse path. The distance across
the alveolar capillary membrane is very small (about 2 microns).
Respiratory Physiology 2010
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Fick’s Law for Diffusion
The diffusion of gases across the blood-gas barrier by simple diffusion is described by Fick’s
law, which states that the volume of gas per unit time diffusing across a tissue is directly
proportional to surface area (A), a diffusion constant (D) (which is proportional to the solubility of
the gas in question and inversely proportional to the molecular weight of the gas) and the partial
pressure difference across the tissue (P1-P2) and is inversely proportional to the tissue thickness (t).
V
DA(P1-P2)
tα
(2.5)
Transfer of O2 and CO2 between Alveolus and Capillary
The time course for transfer of gas between the alveolus and the capillary blood is shown in
Figure 2.1. Even though a red blood cell spends only about 0.75 seconds passing through an
alveolus, the partial pressures of both carbon dioxide and oxygen normally reach equilibrium.
Equilibrium is reached by about 0.3 seconds. Even though the driving pressure for CO2 is lower
(PMVCO2-PACO2 = 46 mm Hg - 40 mm Hg = 6 mm Hg) than for O2 (PAO2 - PMVO2 = 100 - 40 = 60
mm Hg) the solubility of carbon dioxide is much greater. The net result is that the rates of diffusion
for carbon dioxide and oxygen are approximately equal.
Figure 2.1: Time Course for Transfer of Gas Between the Alveolus and the Capillary Blood
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Measurement of Diffusing Capacity
The measurement of diffusing capacity is a valuable pulmonary function test. Early in the course
of interstitial disease, the diffusing capacity test may be the only one that shows abnormal values.
Measurement of diffusing capacity is also useful for following the course of a disease or its response
to treatment.
In order to accurately explain gas diffusion using Fick’s law, it is necessary to know the surface
area and membrane thickness of the alveolar-capillary membrane. However, these measurements
cannot be made in living subjects. Therefore, Fick’s equation is rearranged and terms of diffusivity,
thickness, and surface area are combined into DL,x, where X is the gas being used in the
measurement.
DL,x
V.
PA,x - Ppc,x=
(2.6)
It is very difficult to measure the diffusing capacity of the lung for oxygen, because the partial
pressure of oxygen increases along the pulmonary capillary. This problem does not occur with
carbon monoxide since its partial pressure remains essentially zero along the length of the
pulmonary capillary. The diffusing capacity of the lung for oxygen can be calculated from the
diffusing capacity of the lung for carbon monoxide by a correction factor (see below).
Single-Breath CO Method
Several techniques are used to measure diffusing capacity of the lung for carbon monoxide
(DL,CO). One of the most common tests is the single-breath CO method. Briefly, the patient rapidly
and maximally inhales a gas mixture containing a low concentration of CO and holds his/her breath
for a short period of time. The last part of the expired gas is collected and used to estimate the PACO and the uptake of CO (VCO). An advantage of this technique is that it is rapid. One disadvantage is
that some patients have difficulty holding their breath for even a short period of time. A detailed
discussion of the methodology is beyond the scope of this course. Interested readers are referred to
the chapter on diffusion (p398) in Laboratory Evaluation of Pulmonary Function, J.B. Lippincott
Company, Philadelphia. The diffusing capacity of the lung for oxygen can be calculated from the
DLCO according to DLO2 = DLCO x 1.23. This calculation takes into account the molecular weights
and solubilities of the two gases.
Effects of Exercise on Diffusing Capacity
DLCO increases with exercise. Capillaries that were previously closed or had low flow through
them are recruited; and pulmonary capillaries that were previously opened are dilated. Note: normal
subjects rarely exhibit diffusion impairment of oxygen transfer even with severe exercise except at
high altitudes, where it can be a major limitation.
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Examples of Diseases that Affect Diffusion of Gases
Diseases Associated with Decrease Surface Area for Diffusion
Emphysema
Destruction of tissues results in destruction of alveolar walls so that a group of alveoli become
one air sac with less surface area for pulmonary blood.
Diseases that Affect “t” (“Thickness”)
Pulmonary Fibrosis
Deposition of fibrous tissue in alveolar walls.
Berylliosis
Associated with inhalation of berylium.
Asbestosis
Associated with inhalation of asbestos.
Sarcoidosis
Multiple granulomatous lesions.
Pulmonary Edema
Accumulation of fluid outside of capillaries.
IMPORTANT NOTE: It is very rare that impaired diffusion exists as a single physiological
abnormality. The process that causes the thickening of the membrane or the decrease in surface
area almost always leads to uneven ventilation, uneven capillary blood flow and therefore, uneven
matching of gas and blood.
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Lung Mechanics
Objectives
• Know the definitions of lung volumes and capacities.
• Know the normal values for total lung capacity, functional residual capacity, tidal volume
and vital capacity.
• Know the formula for the ideal gas law and be able to convert a lung volume measured at
one set of conditions (e.g., BTPS, body temperature, pressure, saturated) to another set of
conditions (e.g., STPD, standard temperature, pressure, dry).
• Understand the measurement of lung volumes by the method of gas dilution and body
plethysmography.
• Describe how a pressure gradient is generated between the atmosphere and the alveoli.
• Know the definition of compliance, and how it is measured.
• Describe the factors involved in the elastic recoil of the lung.
• Describe the pressure-volume characteristics of the lung and chest wall. Understand the
concept of how the interaction of the lung and chest wall relates to the negative intrapleural
pressure.
• Define airways resistance. Be able to relate how airway diameter, lung volume and elastic
recoil properties of the lung affect airways resistance.
• Describe what happens during dynamic compression of the airways during a forced
ventilation.
• Predict how pathological conditions such as obstructive and restrictive lung disease affect
flow-volume curves.
NOTE: Objectives 1-4 (regarding lung volumes) will be covered in laboratory.
Overview
In order to study respiratory physiology, it is necessary to define the lung volumes and capacities
that are most commonly used to describe lung function. When the volumes are measured under
standard conditions used in pulmonary function laboratories, they can be compared between patients
or with time during the course of a disease in a single patient. Changes in these volumes and
capacities, which are the sum of more than one volume, are often indicative of lung disease.
Although it is important to know the definitions of the lung volumes and what “predicted” or normal
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values are for these volumes, it is equally, if not more important, to understand the mechanical
factors that are involved in breathing. Taylor defines lung mechanics as the study of the pressures
acting on the respiratory system and the changes in volume that they produce. We will approach the
study of lung mechanics by:
• Defining lung volumes and capacities and how they are measured.
• Defining the pressures involved in normal breathing and how they are generated.
• Discussing the elastic recoil forces of the lung and chest wall and the pressures that must be
generated to overcome these forces in normal breathing (static behavior).
• Discuss resistances to airflow (dynamic process).
Pressures of the Respiratory System
Units of Pressure Measurements
Pressures in the cardiovascular system are usually measured in mm Hg. The units of pressure
measurement of gas tensions are also usually in mm Hg. However, when discussing lung mechanics
and ventilation, respiratory physiologists tend to measure pressure in and around the respiratory
system in cm H2O. Unless otherwise indicated, the pressure measurements are relative to
atmospheric pressure. The units of cm H2O are used because the relevant changes in pressure are
small and 760 mm Hg = 1,033 cm H2O. By convention, atmospheric pressure is referred to as 0 cm
H2O. Thus, the statement that alveolar pressure is 5 cm H2O really means that alveolar pressure is 5
cm greater than atmospheric pressure. If the measurement were made at sea level (760 mm Hg or
1,033 cm H2O), then the absolute pressure (compared to a vacuum with no pressure) would be
1,038cm H2O. Pulmonary physicians and physiologists are generally only concerned with pressures
relative to atmospheric. A pressure of -5 cm H2O means that the pressure is 5 cm H2O less than
atmospheric pressure.
Intrapleural Pressure
The pleural space is a true anatomic cavity. However, it is perhaps best to think of this space as a
tissue space. The cavity normally contains a small amount of incompressible liquid (about 0.1 to 0.3
ml/kg body weight) which probably has a low concentration of protein. There is normally no gas in
the pleural space. The fluid is spread out very thinly so that the visceral and parietal pleura do not
actually touch. But because the pleural fluid is just a small fixed volume, the lungs and the chest wall
must always change in volume by the same amount (unless a stab wound or lung rupture admits
some air into the pleural space). Pleural pressure is usually measured indirectly. The patient
swallows a soft-walled balloon attached to a pressure transducer. The balloon, which stays in the
lower part of the esophagus is in the thorax between the lungs and the chest wall. Since the
esophagus is thin-walled, changes in intrapleural pressure will be transmitted to the esophagus and to
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the balloon inside it. For reasons that will be described later, the intrapleural pressure is normally 4
to 5 cm H2O lower than atmospheric or -4 to -5 cm H2O.
Transmural Pressures
The transmural or transwall pressure is the force that tends to distend a structure. Respiratory
physiologists are concerned with two “structures”, the lung and the chest wall and with three
transwall pressures as diagrammed above. The transpulmonary pressure (PL) is calculated by
subtracting intrapleural pressure (PPL) from alveolar pressure (PA). The transchest wall pressure is
calculated by subtracting pressure on the outside of the chest from intrapleural pressure. The
transtotal system pressure is calculated by subtracting the pressure on the outside of the chest from
alveolar pressure.
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Recoil of the Lungs
If a person is stabbed in the chest with a knife admitting air to the pleural space, you would
observe that the lungs would collapse and the chest wall would expand. This condition is called a
pneumothorax. At normal lung volumes, the lung tends to collapse (“recoil”) and the chest wall
tends to expand. The lungs tend to collapse as a consequence of two factors:
• Collagen and elastin fibers
• Surface tension
Collagen And Elastin Fibers
The collagen and elastin fibers in the lung are functionally somewhat like nylon in nylon
stockings. Each individual fiber is not easily stretched, however, when stockings are manufactured,
the fibers are woven together in such a way that the stocking is easy to stretch or distend. Also, after
the stockings are stretched, they will return to their original size. When the inspiratory muscles
contract and expand the chest wall, the lungs are expanded. When the muscles relax, the lung tends
to “recoil” or return to its resting volume.
Surface Tension
The second force that contributes to the recoil properties of the lung is the surface tension which
exists at the alveolar gas-tissue interface. Surface tension is caused by the cohesive or attractant
force between water molecules. For example, water tends to form rounded drops due to the surface
tension generated by the attraction of water molecules to one another. The epithelium of the alveoli
is covered by a thin layer of liquid, the molecules of which will be attracted to one another making
the surface of the alveoli shrink to the smallest possible area. This tendency is offset by a unique
material called lung surfactant. Lung surfactant is synthesized by the alveolar type II cell and
secreted into the alveolar space (see Figure 3.2). Surfactant consists of both lipid and protein
components and is enriched in the lipid, dipalmitoylphosphatidylcholine (DPPC). It is generally
accepted that the DPPC is the component that is primarily responsible for reducing the surface
tension to very low levels. The DPPC is inserted perpendicularly into the gas-liquid interface so that
its non-polar, hydrophobic fatty acids (palmitate) are pointed toward the gas and its polar end is in
the liquid. The DPPC probably forms a monolayer that generates a film pressure that opposes the
surface tension. Also when the film is compressed (as the volume of the lungs is reduced) the film
pressure rises and surface tension falls even further. This property makes the lungs more stable.
The lungs of many premature babies are unable to produce adequate amounts of functional
surfactant. Approximately 50% of babies born before the 31st week of gestation will suffer from
Respiratory Distress Syndrome. Because of the lack of surfactant, the surface tension in their lungs
is high, which increases the tendency of the lungs to collapse. In addition, the babies tend to have
many other medical problems including pulmonary edema, acidosis and damage to the lung tissue
from being mechanically ventilated. New treatments with exogenous surfactants are currently being
used in hospitals world-wide and have reduced infant mortality by approximately 50%.
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Pressure-Volume Curves of the Lung
The elastic recoil properties of the lungs can be assessed by measuring the change in lung
volume as a function of the change in transpulmonary pressure. Compliance is defined as the change
in volume divided by the change in pressure. (C = ∆V/ ∆P). Volume changes can be measured with a
spirometer. Intrapleural pressure is measured with an esophageal balloon, alveolar pressure is
measured as the pressure at the mouth when there is no airflow. The most common way to obtain a
compliance curve is to have a patient inspire to total lung capacity and then expire slowly in small
increments. When airflow is temporarily stopped, volume and transpulmonary pressure are recorded.
A pressure-volume curve such as that shown in Figure 3.3 is constructed. The slope of the pressure
volume curve at any given point is lung compliance at that point. The pressure-volume curve is not
linear, since at high lung volumes the lungs are almost maximally stretched and a large change in
pressure produces only a small change in volume. Therefore, compliance is usually measured in the
mid-range of the pressure volume curve during tidal volume breathing near the resting FRC. A
normal value for lung compliance at this point is 0.2 liter/cm H2O.
Compliance also varies with lung size. A small lung will have a smaller volume change per unit
change in transpulmonary pressure than will a large lung. Compliance is therefore usually
normalized by dividing by functional residual capacity to give specific compliance. Most
mammalian lungs have a specific compliance of 0.08/cm H2O.
Figure. 3.2: Synthesis of Surfactant
Surfactant is synthesized by type II cells and stored in unique intracellular organelles called
lamellar bodies. The lamellar body contents are secreted into the liquid covering the cells. a
monomolecular surface film of dipalmitoylphosphatidylcholine (DPPC) is formed which
lowers surface tension of the air-liquie interface. The DPPC is inserted with its fatty acids
oriented toward the air and its polar head group in the liquid.
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Figure. 3.3: Pressure-Volume Curve of the Lung
An esophageal balloon attached to an external pressure transducer measures
changes in intrapleural pressure. Lung volume is measured with a spirometer.
Figure. 3.4: Volume vs. inflation pressure during lung inflation with air and
saline. Compliance is greater with saline.
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Effects of Surfactant on Alveolar Stability
Alveolar stability is also affected by surface tension. Practically speaking, alveoli can be
considered to be spheres. In a sphere, surface tension creates a force that tends to pull inward and
create a pressure. The relationship between surface tension and pressure inside a sphere is shown in
Figure 3.5 and is defined by the law of Laplace. According to Laplace, transmural pressure is equal
to twice the surface tension divided by the radius (P=2T/r).
If surface tension were equal (50 dynes/cm in our example) in alveoli of different sizes, the
pressure in the smaller alveolus would be greater than the pressure in the large alveolus and the
smaller alveolus would collapse into the larger one. This alveolar collapse is known as atelectasis.
This does not normally happen because the surface tension in a lung with surfactant is not constant
at 50 dynes/cm. As described above, surfactant reduces surface tension is a nonlinear fashion; i.e., as
area is reduced, surface tension is reduced even further. Thus by lowering surface tension
proportionately more in smaller alveoli, surfactant makes it possible for alveoli of different radii to
coexist and to be stable at low lung volumes.
During normal tidal breathing, the surface area of the lung remains fairly constant and with time
the surfactant becomes “inactivated” through poorly understood mechanisms. A deep sigh or a yawn
will increase the surface area of the lungs and new surfactant will spread at the air-liquid interface.
For this reason, post-surgical patients who have had anesthesia are often encouraged to breath deeply
to enhance the spreading of surfactant and prevent lung collapse.
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Figure. 3.5: Surfactant alters alveolar stability. In absence of surfactant, surface
tension remains constant (50 dynes/cm in this theoretical model). Alveoli of different
diameters cannot coexist because the pressure in the smaller alveolus is greater than
the pressure in the large alveolus which will cause air to flow from the small alveolus
into the large alveolus. Thus, at low lung volumes, the smaller alveolus tend to
collapse. Surfactant stabilizes the alveoli because surfactant lowers surface tension
proportionately more in the smaller alveolus. Therefore, the pressure in the two
different sized alveoli will be equal and therefore, the alveoli can coexist. T = tension,
r = radius (cm), Dynes = unit of tension
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Lung Compliance & Disease
A very compliant lung is easy to stretch. A lung with low compliance is stiffer and
hard to stretch. Fibrosis and respiratory distress syndrome of the premature newborn are
examples of diseases which are associated with reduced lung compliance. Emphysema
destroys lung tissue and can increase lung compliance. (See Fig. 3.6)
Elastic Recoil of the Chest Wall
The chest wall also has elastic properties that are affected by the stiffness of the thoracic cage
and muscles. The elastic recoil properties of the chest wall can be affected by diseases that cause
spasticity of the abdominal or thoracic muscles. It is important to emphasize that compliance is a
meaningful term only in a passive structure. It is defined as a measure of the inherent recoil
properties of a structure. Therefore, when measuring the compliance of the chest wall it is important
that the muscles of the chest wall be relaxed.
Relaxation Pressure-Volume Curve Of The Respiratory System (Lung + Chest Wall)
Although the lungs and chest wall both have elastic properties that can be discussed separately,
in fact the two structures are connected and their functions are interdependent. As explained above a
pneumothorax causes the chest wall to spring out and the lungs to collapse. Normally the forces that
tend to collapse the lungs oppose the forces that tend to cause the chest wall to spring out. The
balance of these forces determines the resting lung volume. The relationship between the elastic
recoil of the chest wall and the elastic recoil of the lung at various lung volumes can be appreciated
by discussing a relaxation-pressure volume curve.
In order to construct a relaxation pressure-volume curve, the subject inspires or expires from a
spirometer and then relaxes her chest. Lung volume is measured with the spirometer. Intrapleural
pressure is estimated with an esophageal balloon. Alveolar pressure is estimated by measuring
pressure at the mouth during conditions of no flow. Therefore, changes in transpulmonary (PA-PPL),
trans chest wall (PPL-PB) and trans system (PA-PB) pressures can be calculated. The change in
volume of both the lungs and chest wall can be assumed to be approximately the same because the
lung and chest wall are coupled together by the cohesive forces of the fluid in the pleural space.
Remember, compliance is a property of a passive organ (no muscle contraction should be occurring).
It is useful to consider the interactions of the lung and chest wall at a few selected lung volumes.
• At FRC, the forces tending to collapse the lungs are equal but opposite to the forces tending
to expand the chest wall. This is the equilibrium volume of the lung. At FRC, Prs = 0 because
PA = PB = 0.
• At TLC, the lungs and chest wall are both tending to recoil to smaller volumes. See Figure
3.7
• At residual volume, the chest wall is tending to pull outward. This outward pull is balanced
by large negative transchestwall pressures. The lungs are still tending to collapse, although
they are only slightly stretched. This tendency to collapse is balanced by a positive
transpulmonary pressure.
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Figure. 3.6: Deflation Pressure Curves of the “Normal” and Diseased Lung
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END EXPIRATION: At the end of expiration, the muscles of the chest wall are relaxed. The inward
elastic recoil of the lung is balanced by the outward elastic recoil of the chest wall. Recoil tendencies
are indicated by direction of the arrows. The relative recoil tendency is indicated by the thickness of
the arrows. A high recoil tendency is indicated by a thicker arrow. Intrapleural pressure (PPL) is –0.5
cm H2O; alveolar pressure (PA) = 0 cm H2O. The translung pressure difference (PL) = +5 cm H2O).
The elastic recoil of the lungs (arrows) is equal but opposite of the elastic recoil of the chest wall.
DURING INSPIRATION: Contraction of the muscles during inspiration causes the intrapleural
pressure to become more negative. The translung pressure gradient increases and the alveoli are
distended. The tendency of the lung to recoil is greater than at end expiration (above, darker arrows).
The alveolar pressure (PA) drops below atmospheric which results in airflow into the alveoli.
Airway Resistance
Thus far we have discussed the changes in pressure that are required to overcome only the elastic
recoil tendencies of the respiratory system. These measurements were made under conditions of no
air flow. An additional force that must be overcome during normal breathing is the resistance to
airflow. Changes in airway resistance accompany many lung diseases and measurement of it is an
extremely useful diagnostic tool. Flow will depend upon the driving pressure and the resistance
according to the equation:
Flow = Pressure/Resistance.
Therefore,
Resistance = Pressure difference (cm H2O)/flow (Liters/sec)
Resistance is a constant only if airflow is laminar, or smooth. In fact airflow in the airways is not
all laminar, but is also turbulent, in which air molecules are moving laterally and colliding with each
other. Airflow can also be transitional, which is a mixture between laminar and turbulent flow.
Factors that Influence Airway Resistance
Airway Diameter
It is probably intuitive that the more narrow the airway, the higher the resistance in that
individual airways will be. What may not be intuitive is that most of the resistance to air flow is
found in the mouth, trachea and large bronchi. The reason for this is that as the airways divide and
become narrower, they also become more numerous. The small airways divide more rapidly than
their diameter decreases, therefore, the resistance of each individual airway is relatively high, but
their total-cross sectional area is so great that their combined resistance is low. Even though
relatively little of the total resistance to breathing is found in the small airways, they are the most
susceptible to disease-induced changes in resistance to air flow.
Lung Volume
The diameter of the airway lumen is affected by lung volume. The airways are not rigid and are
capable of being distended and compressed. The bronchi and the smaller airways are intimately
connected with the lung parenchyma and functionally connected to the surrounding lung tissue. At
high lung volumes the airways are “pulled” open and their resistance is lower than at low lung
volumes.
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Elastic Recoil
Airway resistance is also affected by elastic recoil properties of the lung tissue. Airway diameter
will be affected by the transmural pressure across them. Although the airways are embedded in the
parenchyma the pressure that they are exposed to on their outside wall is close to intrapleural
pressure. Thus their transmural pressure = Pin the airways - Ppl. If elastic recoil of the lung tissue is
reduced, then pleural pressure will be less negative than normal, since the tendency of the lungs to
recoil from the chest wall will be reduced. The transmural pressure across the airways will be lower,
the airway diameter will be smaller than normal, and resistance will be higher than normal. Patients
with emphysema often have destruction of lung tissue, decreased elastic recoil (increased
compliance), and increased airway resistance.
Airway Smooth Muscle Tone
Constriction of bronchial smooth muscle will decrease the diameter of the airways and also
increase airway resistance. Parasympathetic stimulation causes contraction; sympathetic stimulation
causes relaxation. Asthmatics often have hyperreactive airways and smooth muscle contraction.
Drugs which stimulate beta-adrenergic receptors in the bronchioles cause relaxation and are often
used to treat asthmatics.
Measurement of Airway Resistance
For practical purposes we can assume that flow through the airways is laminar and that airway
resistance can be approximated by the equation: R = driving pressure/ flow = PA-Pmouth/flow. Flow
can be easily measured with a pneumotachograph. The measurement of PA is difficult. Alveolar
pressure can be measured directly by a body plethysmograph. The details of this measurement are
beyond the scope of our discussion.
Forced Expiratory Vital Capacity Curve
Examples of a normal and forced expiratory vital capacity curve are shown in Figure 3.8. This is
a somewhat indirect but very valuable assessment of airway resistance. The advantages of this
technique are that the procedure is highly reproducible, easy to perform, and sensitive. The subject
simply inhales to total lung capacity, and then exhales into a spirometer as forcefully, rapidly, and as
completely as possible. The volume expired under these conditions is called the forced vital capacity
(FVC). The volume exhaled in 1 second is called the 1-second forced expiratory volume (FEV1). It
is useful to express this value as a % of FVC (FEV1/FVC). Normally FEV1 is at least 80% of FVC.
This value will be reduced in patients such as asthmatics who have obstructed airways. The forced
expiratory flow 25-75% (FEF25-75%) can also be estimated from the same data. The flow at these
two points is connected by a straight line. Thus, the slope of this line in a patient with obstructed
airways would be less than the slope of a line obtained from a patient with normal airways.
Dynamic Airway Compression
The airways close when the pressure outside them is greater than the pressure inside them (i.e.,
transmural pressure is negative). During forced expiration, the muscles of the chest wall generate a
positive intrapleural pressure. Alveolar pressure must also be positive in order for exhalation to
occur. As air flows out of the alveoli, the pressure in the airways drops due to the resistance to flow
along the airways. Eventually the pressure drops far enough so that the airway pressure becomes less
than the intrapleural pressure and the airways collapse. Further expiratory effort will only augment
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the compression downstream and therefore, this portion of the flow-volume curve is effort
independent. When flow stops, the airway pressure increases to equal alveolar pressure which opens
the airways. This opening and closing of the airways produces the wheezing sound often heard in
asthmatics. See Figure 3.8.
Figure. 3.8: Forced Expiratory Vital Capacity Curve
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Figure. 3.9: Dynamic airway compression.
A decrease in elastic recoil (increased compliance) results in decreased driving
pressure and airway collapse during forced expiration.