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Pulmonary Physiology
Respiration
Chris L. Wells, PhD, PT, CCS, ATC
BSII: 2015

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Three Phases of Respiration

Ventilation
Diffusion
Perfusion

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Movement System
Mitochondria

CO2

Muscle

Mitochondria

O2

Aerobic or
Anaerobic
Metabolism

Veins

S
y
s
t
e
m
I
c

Arteries

Right Heart

Veins

Heart

P
u
l
m
o
n
a
r
y

Left Heart Arteries

Heart Pump
Cardiac Output
CO = HR x SV

Expired Air

CO2
Production

VCO2
Lungs
VO2

Inspired Air
O2
Consumption

Lung Pump
Minute Ventilation
VE = RR x TV

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Adapted from: Wasserman, Lea & Febriger, 1987: S Tepper 2013

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Functions of Ventilation
Exchange O2 and CO2
pH balance
Hormone function
Temperature regulation
Pressure regulation: thoracic / abdominal
Association with
Balance
Airway clearance
Incontinence

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Chest Wall
Pediatric:

Adults

Smaller ratio of trunk

Horizontal rib cage
Unstable chest wall
Ineffective accessory muscles

2/3 of trunk
Cone shape
Closed Osseous ring
Normal length tension for
accessory muscles

Response to stress?

Response to stress?

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Age Difference of Lungs

Pediatrics: varies upon age
Infant:
Smaller airways
Higher airway pressure

Less cartilaginous support

Early airway closure

Less alveoli
Surface area for diffusion

Glands
Secretions

Type I fibers of Diaphragm

More susceptible to respiratory insufficiency / failure

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Chest Wall
Purpose:
Protect vital organs
Mobility
Sufficient ventilation
UE function

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Chest Wall Mobility: Breathing

Mechanics
Rib 1:
elevation during inspiration
Joint: inferior

Ribs 2-6 (pump handle)

Anterior and superior direction during inspiration
Joints: downward, anterior and posterior rotation

Ribs 7-10 (bucket handle)

Lateral and superior direction during inspiration
Joints: posterior and lateral, slight downward and posterior rotation

Ribs 11-12
Caliper movement
Little effect on chest wall expansion

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Muscles of Ventilation
Diaphragm
Fiber type
55% slow oxidative type
21% fast oxidative type
24% fast glycolytic type

75% of thoracic volume at rest

Intercostals
?? function
Stabilize rib cage

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Muscles of Ventilation
Accessory Inspiratory

Accessory Expiratory

What muscles could be

recruited by a patient with SCI
above C6?
What would change if injury
level was T8

How would breathing by altered if the patient

had suffered a significant stroke?

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Nervous System
Voluntary sensation / motor
Central Nervous system
Medulla
Ventral: regulates rhythm, voluntary forced exhalation and acts to increase force of
inspiration
Dorsal: controls inspiration and timing

Pons
Pneumotaxic center: controls speed, fine tuning rate
Apneustic center: coordinates speed, activities and prolongs inhalation, overrides
pneumotaxic center to end inspiration

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Nervous System: ANS

Efferent
PNS: via vagus nerve (X)
Medulla to run // with airway
Secrete acetylcholine
Airway muscle contraction (bronchoconstriction)
Vascular dilation (pulmonary vasodilatation)
Glandular secretion

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Nervous System: ANS

Efferent
SNS: spinal cord to thoracic sympathetic ganglia
Also runs // with airways
Primary secrete norepinephrine to bind with
Alpha-adrenergic receptors pulmonary vasoconstriction
Beta-adrenergic receptors bronchodilation
Beta-adrenergic receptors bronchovascular dilation

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Nervous System: non-ANS

Efferent
Along pathway of vagus nerve
Promote nitric oxide production
Airway dilation

May also cause local bronchoconstriction through release of

Substance P and neurokinin A

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Chemoreceptors
Central

Peripheral
Carotid bodies

Upper Medulla

Common carotid bifurcation

Aortic arch

Responsive to CO 2

PaCO2 activates
chemoreceptors
Depth of breathing
Respiratory rate

Hypoxemia ( PaO2)
Ventilation

Hypoxic Drive
COPD

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Reflexes
Hering-Breuer Reflex:

Cough Reflex:

Trachea to bronchioles (smooth

muscle)
Over inflation (800ml > FRC

Larynx to lower bronchi

Chemical / Mechanical stimulation

Respiratory rate
Expiratory time

Rapid inspiration
Epiglottis closes
Abdominals contract
Airway pressure
Vocal cords and epiglottis open
Expectoration

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Reflexes
Stretch reflexes:
ICS and diaphragm Spinal cord
Muscle recruitment Ventilation

Joint / Muscle Receptors

Limb movement ventilation in preparation

Mechanoreceptors arterial circulation

BP hyperventilation
BP hypoventilation

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Nervous System: Afferent

Via Vagus Nerve
Slow adapting receptors (SAR) inflation stretch
Rapid adapting receptors (RAR) changes to

Tidal volume
Respiratory rate
Lung compliance
Responses to mechanical and chemical irritants

Other receptors
Chest wall, muscles, O2, CO2, H+

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Nervous System: Afferent

Juxtacapillary receptors (J receptors ): ?? Function but appears to
Alveoli and capillary beds
Pulmonary edema, PE, CHF, barotrauma
Pulmonary nociceptors / C fibers

Response:
Rapid shallow breathing
Dyspnea

Stimuli

Bradycardia
Hypotension
Bronchoconstriction
Mucus production
Apnea

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Parietal
Sensory nerves

Pleural Space

Visceral
Stomata
Openings into lymphatic drainage

Pleural space / fluid

.26 ml/kg fluid
friction
Airtight seals
Lung expansion

Costophrenic angle
30-45 degree angle

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Clinical Significance
Rib Fracture

Open heart surgery

Disruption of both pleura

Pleural effusion
Loss of costophrenic angel
Clinical results:

Air / blood leak into space

Inspiration
Chest wall
Lung

Compression from Fluid

Atelectasis

Clinical results:
Loss of intrapleural pressure
Lung collapse (PTX)

Compression from fluid:

Atelectasis

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Clinical Significance
Chest tube:

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Review Anatomy of Airway

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Airways

Conducting airways
Upper:
Lower

Respiratory

airways

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Lower Respiratory Tract

Conducting
1-15 generation

Bronchial division
cross sectional area airway
velocity

Larynx

Laminar flow

Cricoid cartilage CPR

airway resistance
work of breathing

Complete ring

Trachea

Allows for gas exchange

Creates normal breath sounds

C shaped rings
Carina : Sternal angle
Airway Management

Main Bronchi
Difference in angles
RLL clinical risk

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Conducting System: Histology

Layers:
Mucosa
Epithelia

Submucosa
Connective tissue, glands
Smooth fibers

Adventitia
Cartilaginous rings

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Conducting System: Histology

Mucosa:
Pseudostratified, ciliated, columnar epithelia
Maintenance of fluid and electrolytes
Key for proper mucus function and transport

Serous cells: secrete Cl- and HCO3 Secretion consistency and pH

Goblet cells: mucous (mucin)

Basement membrane
Key for repair of mucous membrane

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Conducting System: Histology

Mucosa
Mucus Blanket
Gel Layer
Sol Layer
Ciliated Cells

Mucus
Primarily water (97%)
Solute: protein, lipids, minerals
Function:
Protection from toxins and organisms
Fluid balance
Attracts air participles

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Conductive System: Histology

Submucosa
Bronchial glands: role in inflammation, mucin (solute portion of mucus)
Mast cells histamine
Vasodilation
Bronchoconstriction

Smooth muscle
Cartilage

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Conductive System: Histology

Adventitia

Connective tissue
Vascular
Lymph vessels
Adipose tissue

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Conducting System
Dead space
Physiologic dead space is part of TV that does not participate in gas exchange
Anatomical: air from the conducting system
With a TV of 500 ml

150 ml in conducting airway

350 ml in respiratory airways gas exchange

Alveolar: air in alveoli that is not exposed to blood for gas exchange

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Dead Space
Alveolar dead space:
Air in alveoli that is not
exposed to blood flow

Pathological Dead Space

Atelectasis
COPD

Dead Space

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Lower Respiratory Tract:

Respiratory System
12 (15) 23 generation
Function
Conducting air
Gas exchange

Acinus (primary lobule)

Respiratory bronchioles
Alveolar ducts
Alveolar sac (alveolar duct and alveoli)

Alveoli

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Respiratory System: Alveoli

Septa (alveolar walls)
Type I pneumocytes
Cover 93% of surface area
Gas exchange

Type II pneumocytes
7% of surface area
Produce surfactant
Stem cell like Differentiate into type I cells
Repair

Release cytokinnes inflammation

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Surfactant
Composed of phospholipids & proteins
Purpose
Surface tension of alveoli
Shed water from alveoli surface

Function

Work of breathing
Improves compliance
Prevents collapse
Protects alveolar surface

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Respiratory System
Alveolar-capillary membrane
= Respiratory membrane
Type 1 endothelial to erythrocytes
Diffusion: difference in partial pressure
Gas Exchange

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Respiratory System
Macrophages / lymphocytes
Key defense for respiratory system

Interstitial space
Elastin and collagen fibers
Supports alveolar shape

Pores of Kohn (b/w alveoli)

Channels of Lambert (b/w respiratory bronchioles)

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Cleaning Mechanisms of the Lungs

Large Airways
Small Airways
Alveoli

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Bronchial Circulation
Metabolic needs of lung and pleura
Low demand: 1-2% of cardiac output
Compensatory
pulmonary circulation bronchial circulation
risk of pulmonary infarction

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Lymphatic System
Function
Fluid balance
Clears fluid from interstitial and pleural space

Immune defense via

Drainage through lymph fluid
Phagocytosis (macrophages)
Produces lymphocytes and plasma cells

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Ventilation

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Ventilation
Process of moving air in and out of lung
Tidal volume: resting volume inspired or expired
Sufficient to meet metabolic needs

Factors
Pressure: force generated by respiratory muscles
Compliance: ease of air acceptance (chest wall & lung)
Resistance: air flow and tissue resistance against ventilation
Resistance muscles work against to ventilate lungs

Flow: volume changes / time

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Ventilation
Ventilation goes to dependent lungs
Gravity /weight of lungs (upright lung)
More negative pressure upper airways
Leads to larger resting volume in apices

Less negative pressure lower airways

Leads to higher compliance and smaller resting volume

RESULTS
Greater change in volume in lower lung fields

What happens when the patient is supine? Sidelying?

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Ventilation
Ventilation occurs because of transpulmonary pressure
Ptp =
Ppl - Pa
Pressure gradient between
Pleural pressure created by muscles
Inspiration: -7 cm/ H2O pressure

Airway pressure created by lungs

Inspiration: -1 cm/H2O pressure

Leads to a tidal volume ~ .5 L

-5cm. H2O to prevent airway closure (atelectasis)

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Forces Opposing Inhalation

Compliance
Lung parenchyma
Elastin and Collagen
Elasticity = tendency to return to resting state

Frictional forces
Gas flow through airways
Airway resistance

Tissue movement
Lungs, abdomen, diaphragm, rib cage
Ascites, obesity, fibrosis

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Compliance

Resting
Lung Chest Wall = FRC
Functional Residual Capacity
RV+ ERV
Resting balance of
elastic forces
Resting volume

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Functional Residual Capacity

Function
Work of breathing
Gas exchange

Decrease with
Atelectasis
Positioning : standing to supine
Pulmonary fibrosis

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FRC: Clinical Significant

Posture:
Upright: greatest FRC
Reduces airway closure
Maximizes gas exchange

Supine: reduces FRC by 50%

atelectasis

Hospitalization: anesthesia / surgery

Alteration in ventilation mechanics
Alteration in diaphragm position / function

Further reduces FRC

Airway closure
Work of breathing

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FRC: Pathology
Auto Peep:
Is gas trapped in alveoli at end expiration, due to inadequate time for
expiration,
Causes:
Mechanical ventilation:
Decrease expiratory time
Increase expiratory pressure

Airway obstructions (mucous plugs)

Exercise with COPD
Air hunger

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Forces Opposing Inhalation

Airway Resistance: Tracheobronchial flow
Laminar flow
Gas moves in discrete layers
Center flow is faster than air near airway

20% of airway resistance in small airways from laminar

Turbulent flow
Irregular currents
Smaller airways flow
80% of total resistance at upper airway from turbulent

It is the turbulence of air

flow that leads to normal
breath sounds
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Work of Breathing (WOB)

Inhalation:
Compliance: work to expand lungs against elastic forces
Tissue Resistance: work to overcome viscosity of lung and chest wall
Airway Resistance: work to overcome airway resistance

Clinical relevance: What is my

patients problem? Can I, as a Pt,
do something about it?

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Ventilation Activities
Involuntary

Sighing
Laughing
Yawning
Hiccoughing
Vomiting
Sneezing

Exhalation

Signing
Talking
Blowing
Coughing

Breath hold

Inhalation
Sniffing
sucking

Valsalva
Defecation
Heavy exertion

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Diffusion
Crossing the alveoli capillary membranes

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Diffusion
O2
O2

Alveoli

O2
O2

Surfactant
alveolar epithelial
capillary endothelial
plasma
erthyrocyte membrane
intracellular fluid
Hemoglobin

CO2

CO2

CO2

CO2

CO2
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Diffusion
O2
Alveoli

O2

O2
O2

Surfactant
alveolar epithelial

Edema

capillary endothelial

Exudate

Fluid

Fibrosis

CO2

CO2

plasma
erthyrocyte membrane
intracellular fluid
Hemoglobin

CO2

CO2
CO2
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Sarcoidosis, scleroderma,
pulmonary edema, PF

Diffusion

PaCO2
Alveoli
Surfactant

CO2
O2

CO2
CO2

alveolar epithelial
capillary endothelial

CO2

CO2

O2

Hypoxemia
O2

plasma
erthyrocyte membrane

O2

intracellular fluid
Hemoglobin

PaO2
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Air Pressure: = 760 mmHg

Atmospheric Air: Inhale
O2: 159 mmHg (20.84%)
CO2: 0.3 mmHg (0.04%)

Atmospheric Air: Exhale

O2: 120 mmHg (15.7%)
CO2: 27 mmHg (3.6%)

Alveolar Air:
O2 = 104 mmHg (13.6%)
CO2 = 40 mmHg (6.2%)

Pulmonary Capillary
Arterial
PO2 = 40 mmHg
PCO2 = 45 mmHg

Venous
PO2 = 104 mmHg
PCO2 = 40 mmHg
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Gas Pressure Differences

Constant diffusion of gases
Humidification of alveolar air
Only partial exchange of alveolar air
Allows for stable concentrations stable pH

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Diffusion Rate Factors

Thickness of respiratory membrane
Alveoli capillary fused walls
Pathologies
PF
ARDS

Surface area
Clinically significant when reduced to 1/3 to
Pathology
COPD

Pressure gradient

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Diffusion Capacity
Measures diffusion across respiratory membrane
Volume of gas per minute for 1 mmHg pressure difference
O2: 21 ml/min/mmHg at rest
O2: 65 ml/min/mmHg at peak exercise

REMEMBER: What is happening to the

airways and vasculature at times of
exercise (SNS and catecholamine
activation?

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Diffusion Capacity
Possible by opening dominant capillaries and alveoli = O2
saturation
surface area (3 times the active respiratory membrane)
Diffusion occurs in first 1/3 of capillary exposure
2/3 more available time for diffusion to occur

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Perfusion
Pulmonary Circulation available for gas exchange

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Vascular: Pulmonary
Pulmonary

Pulmonary Function

Veins: oxygenated blood

Arteries: deoxygenated
Capillaries within alveolar walls
Covers 90% of alveolar surface
Capillaries more sheet like
coverage over alveoli

Gas exchange
Fluid barrier
Blood reservoir
Filter for blood clots
Clearance
Adenosine, NE, prostaglandins

Conversion of angiotension I to II
Release cytokines
Inflammatory response

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Hemoglobin
97% of O2 is carried by Hemoglobin
3% is dissolved

Normal references:
Male: 14 18 g/dL
Female: 12- 16 g/dL

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Hemoglobin
Low: 8-10 g/dl

High (polycythemia)

exercise tolerance
fatigue
Tachycardia

>20 g/dl
Capillary clotting

< 8 g/dl
High risk of falls in elderly

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Hematocrit
Percentage of packed red cells in volume of
whole blood
Norms:
Males: 42 52%
Females: 37 - 47%

<25% no exercise
YES to FUNCTION

<20% heart failure

Stable?

> 60% spontaneous clotting

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Perfusion
Gravity
Hydrostatic Pressure (weight of blood itself)
15 mmHg less in UL compared to PAP
8 mmHg greater in LL compared to PAP
Perfusion of lower lobes

Exercise: pressure difference is less

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Perfusion
Key Factors
Driving pressure
Vascular resistance
Gravity

Pulmonary arterial pressure increase

Superior to inferior hydrostatic pressure

Less driving pressure in apices than bases

Zones of lungs
Perfusion greatest in dependent position

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Zones of Perfusion

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Shunting
Areas were there is blood flowing by non-aerated alveoli

Shunt

Dead Space
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Oxygenation
Thickness & surface area
Ventilation
Alveolar condition
Oxyhemoglobin dissociation

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Arterial Blood Gases

pH
7.35-7.45
pCO2
35-45 mmHg
pO2
80-100 mmHg
HCO-3
22-26
O2 saturation
95-99% arterial
70-85% venous

SvO2

60-70%

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Pulse Oximeter
Oxygen Carrying Capability
CaO2 = (SpO2 x Hbg x 1.34) + (.003 x PaO2)
Normal 16-20 ml/O2/dL blood

Determine the accuracy

Sensing
Wave form
Heart rate

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Pulse Oximeter
Factors that influence accuracy

Proper sensor / fit

Cool temperature
Tremors
Finger nail polish
Artificial nails
Fungal infections

Peripheral ischemia
Hypotension
Shock

Exercise / weight bearing

Fluorescent lights

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Oxyhemoglobin Dissociation Curve

**
Alkalosis
Acidosis

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Oxyhemoglobin
Dissociation Curve
Shift to the left
Increase in hemoglobin / oxygen affinity
Hemoglobin resistant to give up the oxygen
pH: > 7.4
Causes: alkalosis
Respiratory
Metabolic

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Respiratory Alkalosis
Cause:
Hypoxemia
CNS stimulation
Sepsis, ASA overdose
TBI, tumor
Excessive stress

Hyperventilation
Hepatic encephalopathy
IPF

S/O:
Hypocapnia
Tachypnea
Lightheadedness
Peripheral tingling / tetany
Convulsions
Diaphoresis
Tachy-arrhythmias

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Metabolic Alkalosis
Cause:
Hydochloric acid
Potassium
Diarrhea
Steroids
Diuresis
NG suction
PUD
Massive blood transfusion

S/O:
Hypoventilation
MS
Agitation
Dizziness
Peripheral numbness
Muscle twitching / tetany
Convulsions
Tachy-arrhythmias

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Oxyhemoglobin
Dissociation Curve
Shift to the right
Decrease in hemoglobin / oxygen affinity Hemoglobin gives up oxygen more
readily
pH < 7.4
Causes: acidosis
Respiratory
Metabolic

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Respiratory Acidosis
Cause:
CNS injury to respiratory
center
TBI , tumor, CVA

COPD
Respiratory ms. Weakness
Flail chest
CNS depressant drugs

S/O:
Hypoventilation
Hypercapnia
Headache
Visual disturbance
Confusion, anxiety
MS, Coma
Brady-arrhythmias
VF arrest

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Metabolic Acidosis
Cause:
Uncontrolled DM
Starvation
Renal failure
ASA overdose
Prolonged stress
Hypoxia
Severe diarrhea
ETOH
Lactic acidosis

S/O:
Headache
MS / stupor / coma
Hyperventilation
Deep respiration
Brady-arrhythmias
Muscle twitching
N/V/D
Malaise

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Acid Base Balance

Normal
Range
pH

7.35-3.45

Acid

7.40 Alkaline

PaCO2 35-45

Alkaline 40

Acid

HCO-3

Acid

Alkaline

22-26

24

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Determining Acid Base Balance

Determine which side of the acid base balance is each value

pH 7.21
PaCO2: 67
HCO-3: 28

acid
acid
alkaline

Circle the two that are similar:

Ex:

acid

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Determining Acid Base Balance

To determine if the disorder is respiratory or metabolic:
Acidosis:
Respiratory: if CO2 is circled
Metabolic: if HCO-3 is circled

Alkalosis:
Respiratory: if CO2 is circled
Metabolic: if HCO-3 is circled

Ex: Respiratory

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Determining Acid Base Balance

To determine the extent of compensation:
Absent:
pH is OUTSIDE of normal range
One value (PaCO2 or HCO-3) is WITHIN normal range
One value (PaCO2 or HCO-3) is OUTSIDE normal range

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Determining Acid Base Balance

To determine the extent of compensation:
Partial:
pH is OUTSIDE normal range
PaCO2 and HCO-3 are outside normal range

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Determining Acid Base Balance

Complete:
pH is WITHIN normal range
One value (PaCO2 or HCO-3) is OUTSIDE normal
Second value has changed sufficiently to place pH WITHIN range

Ex: Partial Respiratory Acidosis

pH 7.21
acid
PaCO2: 67
acid
HCO-3: 28 alkaline

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Acid Base Balance

1. Age 57, IPF
PaO2 :
70
pH
7.47
PaCO2
25
-3
HCO
14

2. Age 15, asthma

PaO2 :
70
pH
7.50
PaCO2
28
-3
HCO
24

3. Age 71, lasix

PaO2
77
pH
7.50
PaCO2
48
-3
HCO
37

4. Age 67, COPD

PaO2 :
62
pH
7.38
PaCO2
46
-3
HCO
28

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