23-1

•
Ventilation : Movement of air into and out of lungs
•
External respiration : Gas exchange between air in lungs and blood
• Transport of oxygen and carbon dioxide in the blood
•
Internal respiration : Gas exchange between the blood and tissues
23-2

Respiratory System Functions
•
Gas exchange : Oxygen enters blood and carbon dioxide leaves
•
Regulation of blood pH : Altered by changing blood carbon dioxide levels
•
Voice production : Movement of air past vocal folds makes sound and speech
•
Olfaction : Smell occurs when airborne molecules drawn into nasal cavity
•
Protection : Against microorganisms by preventing entry and removing them
23-3

•
Upper tract
–
Nose, pharynx and associated structures
•
Lower tract
–
Larynx, trachea, bronchi, lungs
23-4

•
Nose
–
External nose •
Pharynx
–
Nasal cavity –
Common opening
• Functions for digestive and
–
Passageway for air respiratory systems
–
Cleans the air
–
Three regions
–
Humidifies, warms air
• Nasopharynx
–
Smell
• Oropharynx
–
Along with paranasal
• Laryngopharynx sinuses are resonating chambers for speech
23-5

•
Functions
–
Maintain an open passageway for air movement
–
Epiglottis and vestibular folds prevent swallowed material from moving into larynx
–
Vocal folds are primary source of sound production
23-6

23-7

Insert Fig 23.5 all but b
• Windpipe
• Divides to form
– Primary bronchi
23-8

•
Conducting zone
–
Trachea to terminal bronchioles which is ciliated for removal of debris
–
Passageway for air movement
–
Cartilage holds tube system open and smooth muscle controls tube diameter
•
Respiratory zone
–
Respiratory bronchioles to alveoli
–
Site for gas exchange
23-9

23-10

23-11

•
Two lungs : Principal organs of respiration
–
Right lung : Three lobes
–
Left lung : Two lobes
•
Divisions
–
Lobes, bronchopulmonary segments, lobules
23-12

• Movement of air into and out of lungs
• Air moves from area of higher pressure to area of lower pressure
• Pressure is inversely related to volume
23-13

23-14

• Basic Chest X-Ray Interpretation
•Deb Updegraff, C.N.S., PICU

•X-rays- describe radiation which is part of the
•spectrum which includes visible light, gamma rays and cosmic radiation.
•Unlike visible light, radiation passes through stuff.
•When you shine a beam of X-Ray at a person
•and put a film on the other side of them a shadow is produced of the inside of their body.

•Different tissues in our body absorb X-rays at different extents:
•Bone- high absorption (white)
•Tissue- somewhere in the middle absorption (grey)
•Air- low absorption (black)

• First determine is the film a PA or AP view.
PA the x-rays penetrate through the back of the patient on to the film
AP the x-rays penetrate through the front of the patient on to the film.
All x-rays in the PICU are portable and are AP view

• Is the film over or under penetrated if under penetrated you will not be able to see the thoracic vertebrae.

• Check for rotation
– Does the thoracic spine align in the center of the sternum and between the clavicles?
– Are the clavicles level?

LUNG VOLUMES
•
The total volume contained in the lung at the end of a maximal inspiration is subdivided into volumes and subdivided into capacities.
•
There are four volume subdivisions which:
• do not overlap.
• can not be further divided.
• when added together equal total lung capacity.

• Lung capacities are subdivisions of total volume that include two or more of the 4 basic lung volumes.

Basic lung volumes (memorize)
•
Tidal Volume (TV). The amount of gas inspired or expired with each breath.
•
Inspiratory Reserve Volume (IRV).
Maximum amount of additional air that can be inspired from the end of a normal inspiration.

Basic lung volumes (memorize)
•
Expiratory Reserve Volume (ERV). The maximum volume of additional air that can be expired from the end of a normal expiration.
•
Residual Volume (RV). The volume of air remaining in the lung after a maximal expiration. This is the only lung volume which cannot be measured with a spirometer.

Basic lung capacities (memorize)
•
Total Lung Capacity (TLC). The volume of air contained in the lungs at the end of a maximal inspiration. Called a capacity because it is the sum of the 4 basic lung volumes. TLC=RV+IRV+TV+ERV

Basic lung capacities (memorize)
•
Vital Capacity (VC). The maximum volume of air that can be forcefully expelled from the lungs following a maximal inspiration. Called a capacity because it is the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume.
VC=IRV+TV+ERV=TLC-RV

Basic lung capacities (memorize)
•
Functional Residual Capacity (FRC) .
The volume of air remaining in the lung at the end of a normal expiration. Called a capacity because it equals residual volume plus expiratory reserve volume.
FRC=RV+ERV

Basic lung capacities (memorize)
•
Inspiratory Capacity (IC) . Maximum volume of air that can be inspired from end expiratory position. Called a capacity because it is the sum of tidal volume and inspiratory reserve volume.
This capacity is of less clinical significance than the other three.
IC=TV+IRV

• Look at the diaphram: for tenting free air abnormal elevation
• Margins should be sharp
( the right hemidiaphram is usually slightly higher than the left
)

• Size
• Shape
• Silhouette-margins should be sharp
• Diameter (>1/2 thoracic diameter is enlarged heart)
Remember: AP views make heart appear larger than it actually is
.

•
Cardiac Silhouette
1. R Atrium
2. R Ventricle
4. Superior Vena
Cava
7. Pulmonary Valve
8. Pulmonary Trunk
• 9. R PA 10. L PA

•
Margins should
• be sharp

• Loss of Sharp
Costophrenic Angles

• The hilar – the large blood vessels going to and from the lung at the root of each lung where it meets the heart.
• Check for size and shape of aorta, nodes,enlarged vessels

• Infiltrates
• Increased interstitial markings
• Masses
• Absence of normal margins
• Air bronchograms
• Increased vascularity

•
Lung recoil
–
Causes alveoli to collapse resulting from
• Elastic recoil and surface tension
– Surfactant: Reduces tendency of lungs to collapse
•
Pleural pressure
–
Negative pressure can cause alveoli to expand
–
Pneumothorax is an opening between pleural cavity and air that causes a loss of pleural pressure
23-59

•
Tidal volume
– Volume of air inspired or expired during a normal inspiration or expiration
•
Inspiratory reserve volume
–
Amount of air inspired forcefully after inspiration of normal tidal volume
•
Expiratory reserve volume
– Amount of air forcefully expired after expiration of normal tidal volume
•
Residual volume
–
Volume of air remaining in respiratory passages and lungs after the most forceful expiration
23-60

•
Inspiratory capacity
–
Tidal volume plus inspiratory reserve volume
•
Functional residual capacity
– Expiratory reserve volume plus the residual volume
•
Vital capacity
– Sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume
•
Total lung capacity
– Sum of inspiratory and expiratory reserve volumes plus the tidal volume and residual volume
23-61

23-62

•
Minute ventilation : Total amount of air moved into and out of respiratory system per minute
•
Respiratory rate or frequency : Number of breaths taken per minute
•
Anatomic dead space : Part of respiratory system where gas exchange does not take place
•
Alveolar ventilation : How much air per minute enters the parts of the respiratory system in which gas exchange takes place
23-63

•
Partial pressure
–
The pressure exerted by each type of gas in a mixture
– Dalton’s law
–
Water vapor pressure
•
Diffusion of gases through liquids
–
Concentration of a gas in a liquid is determined by its partial pressure and its solubility coefficient
– Henry’s law
23-64

• Diffusion of gases through the respiratory membrane
– Depends on membrane’s thickness, the diffusion coefficient of gas, surface areas of membrane, partial pressure of gases in alveoli and blood
• Relationship between ventilation and pulmonary capillary flow
–
Increased ventilation or increased pulmonary capillary blood flow increases gas exchange
–
Physiologic shunt is deoxygenated blood returning from lungs
23-65

• Oxygen
–
Moves from alveoli into blood. Blood is almost completely saturated with oxygen when it leaves the capillary
–
P0
2 in blood decreases because of mixing with deoxygenated blood
–
Oxygen moves from tissue capillaries into the tissues
• Carbon dioxide
–
Moves from tissues into tissue capillaries
–
Moves from pulmonary capillaries into the alveoli
23-66

23-67

• Oxygen is transported by hemoglobin (98.5%) and is dissolved in plasma (1.5%)
• Oxygen-hemoglobin dissociation curve shows that hemoglobin is almost completely saturated when
P0
2 is 80 mm Hg or above. At lower partial pressures, the hemoglobin releases oxygen.
• A shift of the curve to the left because of an increase in pH, a decrease in carbon dioxide, or a decrease in temperature results in an increase in the ability of hemoglobin to hold oxygen
23-68

• A shift of the curve to the right because of a decrease in pH, an increase in carbon dioxide, or an increase in temperature results in a decrease in the ability of hemoglobin to hold oxygen
• The substance 2.3-bisphosphoglycerate increases the ability of hemoglobin to release oxygen
• Fetal hemoglobin has a higher affinity for oxygen than does maternal
23-69

23-70

23-71

23-72

• Carbon dioxide is transported as bicarbonate ions
(70%) in combination with blood proteins (23%) and in solution with plasma (7%)
• Hemoglobin that has released oxygen binds more readily to carbon dioxide than hemoglobin that has oxygen bound to it (Haldane effect)
• In tissue capillaries, carbon dioxide combines with water inside RBCs to form carbonic acid which dissociates to form bicarbonate ions and hydrogen ions
23-73

• In lung capillaries, bicarbonate ions and hydrogen ions move into RBCs and chloride ions move out.
Bicarbonate ions combine with hydrogen ions to form carbonic acid. The carbonic acid is converted to carbon dioxide and water. The carbon dioxide diffuses out of the RBCs.
• Increased plasma carbon dioxide lowers blood pH.
The respiratory system regulates blood pH by regulating plasma carbon dioxide levels
23-74

23-75

•
Medullary respiratory center
–
Dorsal groups stimulate the diaphragm
–
Ventral groups stimulate the intercostal and abdominal muscles
•
Pontine (pneumotaxic) respiratory group
–
Involved with switching between inspiration and expiration
23-76

23-77

•
Starting inspiration
– Medullary respiratory center neurons are continuously active
– Center receives stimulation from receptors and simulation from parts of brain concerned with voluntary respiratory movements and emotion
– Combined input from all sources causes action potentials to stimulate respiratory muscles
• Increasing inspiration
– More and more neurons are activated
• Stopping inspiration
– Neurons stimulating also responsible for stopping inspiration and receive input from pontine group and stretch receptors in lungs. Inhibitory neurons activated and relaxation of respiratory muscles results in expiration.
23-78

• Cerebral and limbic system
– Respiration can be voluntarily controlled and modified by emotions
• Chemical control
–
Carbon dioxide is major regulator
• Increase or decrease in pH can stimulate chemosensitive area, causing a greater rate and depth of respiration
–
Oxygen levels in blood affect respiration when a
50% or greater decrease from normal levels exists
23-79

23-80

23-81

• Limits the degree of inspiration and prevents overinflation of the lungs
–
Infants
• Reflex plays a role in regulating basic rhythm of breathing and preventing overinflation of lungs
–
Adults
• Reflex important only when tidal volume large as in exercise
23-82

•
Ventilation increases abruptly
–
At onset of exercise
–
Movement of limbs has strong influence
–
Learned component
•
Ventilation increases gradually
–
After immediate increase, gradual increase occurs
(4-6 minutes)
–
Anaerobic threshold is highest level of exercise without causing significant change in blood pH
• If exceeded, lactic acid produced by skeletal muscles
23-83

• Vital capacity and maximum minute ventilation decrease
• Residual volume and dead space increase
• Ability to remove mucus from respiratory passageways decreases
• Gas exchange across respiratory membrane is reduced
23-84