ANATOMI FISIOLOGI

PERNAPASAN

DEPARTEMENT OF ANESTHESIOLOGY &

REANIMATION
MEDICAL FACULTY OF GADJAHMADA
UNIVERSITY
DR SARDJITO GENERAL HOSPITAL
YOGYAKARTA

INTRODUCTION
A person can live for weeks without food and a few days
without water but only a few minutes without oxygen.
Every cell in the body needs a constant supply of oxygen
to produce energy to grow, repair or replace itself, and
maintain vital functions.
The oxygen must be provided to the cells in a way that
they can use.
It must be brought into the body as air that is cleaned,
cooled or heated, humidified, and delivered in the right
amounts.

THE BODYS NEED FOR OXYGEN

Living tissue must have oxygen to survive.

Brain death in humans occurs within 6 to 10 minutes of
tissue anoxia.
Rapid and safe airway control is paramount to the
successful management of critically ill and injured
patients.

Respiratory Physiology
Breathing
Respiration, has three basic steps:
Pulmonary

Ventilation the movement of air into

and out of the lungs

External

respiration: exchange of gases between

the alveoli and the blood in pulmonarry capillaries

Internal

respiration : exchange of gases between

blood in systemic capillaries and tissue cells

Pressure in Thoracic Cavity

Respiratory

pressures are always described relative to

atmospheric pressure

Boyles

Law:
Volume of gas is inversely proportional to pressure
(if temperature constant)

Volume= Constant
Pressure
So, when the volume of the container increases
(expansion of the lungs), the pressure decreases

Boyles Law

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

Pressure in Thoracic Cavity

Atmospheric Pressure (Patm) - pressure exerted

by the air surrounding the body. At sea level
its equal to 760mmHg.
Intrapulmonary Pressure (Palv) - pressure
exerted by the air within the alveoli. It rises
and falls during inspiration and expiration,
but it always equalizes with atmospheric
pressure.
Intrapleural Pressure (Pip) - pressure within the
pleural cavity. It is always lower than both
atmospheric pressure and intrapulmonary

Lung Tissue

It is elastic and has a

tendency to recoil
Ribs want to expand
outward
Lungs want to collapse
Since the pressure in the plural space is
lower than in the alveoli, the alveoli do not
collapse.

Inspiration

Contraction of the diaphragm and

external intercostal muscles increases
the size of the thorax (thereby
decreasing the intra-pleural pressure)
and the lungs expand.

Alveolar pressure falls below

atmospheric pressure.

Intra-pleural (thoracic) pressure is

always 4 mmHg less than the
atmospheric pressure just before

Inspiration

Expansion of the lungs decreased

alveolar pressure to 758 mm Hg

Atmospheric pressure is 760 mm Hg

Air flows into the lungs because of this

pressure gradient

Inspiration causes intra-pleural

pressure to decrease to 754 mm Hg

EXPIRATION

Air is forced out

of the lungs as
the muscles
relax reducing
the volume of
the chest cavity
and increasing
the pressure

EXPIRATION

Occurs when alveolar pressure is higher

than atmospheric pressure
762 mm Hg

Elastic recoil of the chest wall and lungs

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

Air moves out

Quiet breathing does not take any effort (no

Pulmonary Ventilation
Other 3 Major Factors :
Alveolar surface
tension
Compliance
Airway resistance

Alveolar surface tension

Surface

tension causes the alveoli to

assume the smallest diameter
Major component of lung elastic recoil

Surfactant

is a phospholipid produced by
Type II cells in alveolar walls
Alters surface tension below the surface
tension of pure water
Prevents alveolar collapse following
expiration
If surface tension is too high, alveoli collapse
and great effort is needed to reopen them

Compliance
Ratio of volume changes caused by pressure changes V/P

Lung Compliance

Thoracic wall Compliance

Low compliance
To get desired volume there must be higher pressure

High compliance
Low pressure will give high tidal volume

COMPLIANCE (COMPL)
BALLOON
stiff

LOW
COMPLIANCE

Elastis

HIGH
COMPLIANCE

Resistance

The walls of the respiratory passageways

have resistance to the normal flow of air
into the lungs
The smaller the diameter, the greater the
resistance
Any condition that obstructs the air
passageway increases resistance, and more
pressure is need to force air through

Asthma
Inflammation due to infection
COPD

AIRWAY RESISTANCE
(RAW)

FLOW =

BRONCHOCONSTRICTION:

PRESSURE

RESISTANCE

OBSTRUCTION:
MUCUS / SECRET

AIRWAY
RESISTANCE (RAW)
TOO SMALL
ETT

FLOW =

PRESSURE

RESISTANCE

BRONCHOSPASM
TUMOUR / SECRET

COLLAPSE/ATELECTASIS

Partial Pressure
Daltons

Law: each gas in a mixture of

gases exerts its own pressure as if all
other gases were not present
Air 78% nitrogen, 21% oxygen, 1% other
(CO2)

Partial

pressure of a gas is the pressure

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

Exchange of O2 and CO2

O2

and CO2 Diffuse from areas of higher

partial pressures to areas of lower partial
pressure
Results in exchange of O2 and CO2 in the
alveoli
Alveoli: PAO2=105 mm Hg,

PCO2=40 mm Hg

Capillaries: PvO2=40 mm Hg, PVCO2 =45 mm Hg

Pulmonary vein:PAO2=100

PCO2=40 mm Hg

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

The rate of pulmonary and

systemic gas exchange depends on
several factors:
Partial

pressure difference of the gasses,

Surface area available for gas exchange, in
emfisema surface area decreased exchange
decreased
Diffusion distance, in pulmonary oedema,
build up of interstitial fluid between alveoli
distance higher, exchange decreased
Molecular weight and solubility of the gasses
CO2 diffusion occurs 20 X more rapid than
O2, because CO2 has 24X greater solubility
and the molecular weight 1,2 X greater than
O2

The relationship between Hb

saturation and PO2 O2-Hb
dissociation Curve

Other factors affecting Hbs

affinity for O2
Acidity

(pH) Lower pH will shift the

O2-Hb dissociation curve to the right,
the affinity of Hb for O2 decreased, O2
dissociates more easily from Hb
Partial pressure of CO2 As CO2 rises
the affinity of Hb for O2 decreased, O2
dissociates more easily from Hb, shift
the O2-Hb dissociation curve to the
right. PCO2 and pH are related
because low pH results from high
PCO2.

Temperature,

as temperature
increases, so does the amount of
O2 released from Hb , the O2-Hb
dissociation curve shifted to the
right
2,3 DPG, decreases the affinity of
Hb for O2, O2 dissociates more
easily.

RELATIONSHIP BETWEEN VENTILATION (V)

AND PERFUSION (Q)
Normal V/Q = 1

V/Q > 1
V/Q < 1
shunt

alveolar dead space

Lung volumes and Capacities

Tidal

Volume (TV) : The volume of one

breath, 6-8 ml/kgBW, average 500 ml
Respiratory Rate (RR) : 12-16x
breath/min
Minute ventilation: total volume of
inhaled and exhaled each minute :
MV = TV x RR
= 12 x 500 ml = 6.000 ml = 6
liters/min

Next..
Alveolar

Ventilation : the volume

of air per minute that actually
reaches the respiratory zone,
= ( tidal vol dead space ) x RR
= ( 500 ml 150 ml ) x 12
= 350 ml x 12 = 4200 ml/min

Lung volumes and Capacities

Control of respiration
Respiratory Center, divided into 3 areas:
Medullary rythmic area in medulla
oblongata,to control the basic rhythm.
Nerve impulse in Inspiratory area establish
the basic rhythm. The Expiratory area
inactive during quiet breathing, active
during forceful breathing, impulse from
these area cause contraction of the
intercostal and abdominal muscles.

Pneumotaxic

area in pons
transmit inhibitory impulses to
the inspiratory area, to turn off
the inspiratpry area before the
lungs become too full of air.
Apneustic Area in pons send
impulses to the inspiratory area
that activate it and prolong
inhalation long deep inhalation

Control of respiration

Control of respiration

Chemoreceptor regulation of
respiration
Central

chemoreceptor : in medulla
oblongata , respond to changes in H+
concentration or PCO2 in CSF
Peripheral chemoreceptor : located in
aortic and carotid bodiessensitive to
changes in PO2, H+ , and HCO3 -

Respiratory physiology in
paediatric
There

are several differences in the

respiratory physiology from the adult that
can affect airway management in the
neonate and the infant:

Oxygen consumption (ml/kg/min)

Carbon dioxide production (ml/kg/min)
Tidal volume (ml/kg)
Respiratory rate (per minute)
Vital capacity (ml/kg)
Finctional residual capacity /FRC (ml/kg)

Neonate
(3 kg)

Adult

6-8
6
6
32-35
35
30

3.5
3
6
12-16
70
35

The

increased O2 consumption & CO2

production make the neonate prone
to hipoxia even small periods of
apnea during difficult airway
management may not well tolerated

Reduced

FRC and increased Closing

Vol early closure of the airway
during tidal ventilation, reduced FRC
limits O2 reserves during periode of
apnea & predispose to atelektasis &
Hypoxemia

Work

of breathing increased due to

higher resistance narrow passage
Hagen-Poiseuille formula:
Q = P x x r4
8nl
Q = Flow through a tube ; r = radius ; l =
length
P = Pressure ; n = viscosity
Small reduction in the diameter of airway
markedly reduce the flow, increase the
resistance, increase the work of breathing

Problem ventilation in
pediatric

1. Children obstruct more readily adults

The cricoid ring is the narrowest part
of pediatric airway.
2. Noxious intervention can lead airway
obtruction and precipitate respiratory
arrest
3. Positive presure via bag mask
ventilation cause opposite effect by
stenting the airway open and
relieving the obstruction

Anatomical Differences Between Adults and

Children
Anatomy
Clinical Significance
Large intraoral tongue

Straight blade preferred over

curved to push distensible
anatomy out of the way to
visualize larymx

High tracheal opening : C1 in

infant, C3-C4 at age 7, C4-C5
in adult

High anterior airway position

of the glottic opening
compared in adults

Large Occiput

Sniffing position is preferred.

The large occiput actually
elevated the the head into
sniffing position in infants and
children.

Cricoid ring is the narrowest

portion of the trachea

Uncuffed tubes provide

adequate seal
Correct tube size essential

Consistent anatomical
variation
with age

Younger than 2 years,high

anterior;
2-8 years, trantition; older
than 8 years, small order

Large tonsil and adenoid

Blind nasotracheal intubation

not indicated in children

AIRWAY ANATOMY
Upper airway structures include the:
Mouth
Nose
Pharynx (throat)
- Oropharynx
- Nasopharynx
- Laryngopharynx
Larynx (voice box)
The lower airway structures include the:
Trachea (windpipe)
Bronchi (airways)
Bronchioles
Terminal bronchioles
Alveoli

Vocal cords

The upper airway functions to warm, filter, and humidify

the air before it enters the lower airway
The functions of the lower airway include air conduction,
filtration, warming, humidification, and removal of
foreign particles.
Respiration occurs in the respiratory bronchioles of the
lower airway

RESPIRATORY TRACTS AND STRUCTURE

Mouth
Nose
Pharynx
- Oropharynx
- Nasopharynx
- Laryngopharynx
Larynx
Trachea
Bronchi
Bronchioles
Terminal bronchioles
Respiratory bronchioles
Alveolar ducts
Alveolar sacs
Alveoli

conducting zone
- cavities and tubes
- anatomic dead space

respiratory zone

EXTERNAL NASAL
STRUCTURES
BONY FRAMEWORK
frontal bone
nasal bone
maxilla

CARTILAGINEUS
FRAMEWORK
lateral nasal cartilages
septal catrilages
alar cartilages
external nares (nostril)
fibrous connective and
adipose tissue

NOSE
AND NASAL CAVITIES
Olfactory epithelium for
sense of smell
Pseudostratified ciliated
columnar with goblet cells
lines nasal cavity
Nose hairs at the entrance
to the nose trap large inhaled
particles.

frontal
sinus

superior
concha
sphenoid
sinus

middle
concha
internal
nares
inferior
concha

external
nares

Nasal concha provide air turbulence and

promotes filtration and extra time for warming and humidifying air

PARANASAL SINUSES
to reduce the weight of the
skull,
to produce mucus
to influence voice quality by
acting as resonating chambers.

frontal
sinus

sphenoid
sinus

hard palate

PHARYNX (THROAT)
external nares

connects nasal cavity with

larynx ( 5 inch)
extends from the base of
the skull to 6th cervical
vertebrae

nasal cavity

internal nares

Soft
palate
uvula

pharynx

serves both the respiratory

and digestive systems
epiglottis

three regions according to

location:

glottis

- nasopharynx
- oropharynx
- laryngopharynx
(hypopharynx).

trachea

hard palate

NASO-PHARYNX
from choanae to soft
palate

nasal cavity

openings of auditory
(Eustachian) tubes from
middle ear cavity

Soft
palate

naso
pharynx
uvula

adenoids or
pharyngeal tonsil in roof
area above where
food enters thus towards
the nasal cavity

during swallowing, uvula projects upwards

closing off passage to the nasal cavity

epiglottis
glottis

trachea

hard palate

OROPHARYNX
the portion of the
pharynx that is posterior
to the oral cavity.

nasal cavity

Soft
palate
uvula

oro
pharynx

extends from soft

palate to the epiglottis
area where both food
and air passes

epiglottis
glottis

trachea

hard palate

LARYNGO-PHARYNX
posterior to the epiglottis and
extends to the larynx

nasal cavity

Soft
palate
uvula

at larynx, food and air take

different passageways

laryngo
pharynx
epiglottis
glottis

Histology of the pharynx changes from

pseudostratified epithelium to stratified squamous
epithelium when going from naso-to oro-to laryngopharynx

trachea

LARYNX (VOICE BOX)

Epiglottis
Hyoid bone
Thyrohyoid membrane
Corniculate cartilage
Thyroid cartilage
(Adams apple)
Arytenoid cartilage
Crycothyroid ligament
Cricoid cartilage
Cricotracheal ligament
Thyroid gland
Parathyroid gland
Tracheal cartilage

BRONCHIALE TREE
The trachea and bronchi have
supporting cartilage to keep
airways open
Bronchiole walls contain
more smooth muscle,
a feature used in airflow
regulation

THE RESPIRATORY ZONE

contains alveoli,
tiny walled sacs where
gas exchange occurs
alveolar ducts end in
cluster of alveoli called
alveolar sacs

photomicrograph

ALVEOLI AND PULMONARY CAPILLARIES

The pulmonary artery carry
blood which is low in
oxygen from the heart to the
lungs
These blood vessel branch
repeatedly, forming dense
network of capillaries that
completely surround each
alveolus
O2 and CO2 are
exchanged between the
aveoli and pulmonary
capillaries.
Blood leaves the
capillaries via the pulmonary
vein which transport
oxygenated blood back to
the heart

alveolar macrophage
simple squamous epithelium
(type 1 cell)
surfactan secreting cell
(type 2 cell)
capillary

STRUCTURE OF THE RESPIRATORY

MEMBRANE

O2
CO2
O2
O2
CO2

VENTILATION AND RESPIRATION

IMPORTANT DEFINITIONS
Ventilation
the process of moving a volume of
gas in and out of the lungs

Respiration
gas exchange (O2/CO2) across the
alveolar - capillary membrane
(external)
or at the tissue/cellular level
(internal)

BOYLES LAW
relationship between pressure and volume

volume

pressure

volume

pressure
pressure

volume

pressure

volume

INSPIRATION
muscle contraction

EXPIRATION
Muscle relaxation

INTRAPULMONARY (INTRAALVEOLAR) PRESSURE

CHANGES
Intrapulmonary (intraalveolar) pressure is the pressure within the alveoli.
Between breaths, it equals atmospheric pressure (760 mmHg)

INTRAPULMONARY (INTRAALVEOLAR) PRESSURE

CHANGES

INTRAPLEURAL PRESSURE
the pressure within the pleural cavity, always negatiive, and acts like a
suction to keep the lungs inflated

the negative intrapleural

pressure is due to:
Surface tension of alveolar
fluid
Elasticity of lungs
Elasticity of thoracic wall

the negative intrapleural pressure is due to.

SURFACE TENSION OF ALVEOLAR FLUID

The surface tension of the alveolar

fluid tends to pull each of the alveoli
inward and therefore pulls the entire
lung inward. Surfactan reduce this
force

the negative intrapleural pressure is due to:

ELASTICITY OF LUNGS

the elastic tissue in the lungs tends

to recoil and pull the lungs inward.
As the lung moves away from the
thoracic wall, the cavity becomes
slightly larger, decreasing pressure

the negative intrapleural pressure is due to:

ELASTICITY OF THORACIC WALL

The elastic thoracic wall tends to
pull away from the lung, further
enlarging the pleural cavity and
creating this negative pressure
The surface tension of pleural
fluid resist the actual separation
of the lung and thoracic wall

INTRAPLEURAL PRESSURE CHANGES

INTRAPLEURAL PRESSURE CHANGES

FACTORS AFFECTING VENTILATION:

resistance within the airways

lung compliance
thoracic wall compliance

RESISTANCE WITHIN THE AIRWAY

as air flow into the lungs, the gas molecules encounter
resistance when they strike the walls of the airway.
Therefore the diameter of the airway affects resistance

smooth muscle

elastic fibres

parasympatic neuron

histamin

epinephrine

LUNG COMPLIANCE
The ease with which the lung expand is called lung compliance.
It is primary determined by two factors:
The stretchability of elastic fibres within the lungs
The surface tension within the alveoli
Comp : V / P

the stretchability of elastic

fibres within the lungs

the surface tension within

the alveoli

THORACIC WALL COMPLIANCE

obesity
intraabdominal distension

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