Anatomy & Physiology of the

Respiratory System

Oleh :
dr. Jemmy Tanod, SpAn
To cover 2 areas of the Respiratory system

 The anatomy

 The physiology
Our lecture will cover..
 Function of the respiratory system
 Gross anatomy
 Microscopic anatomy
 Pulmonary circulation
 Control of respiration
 Mechanics of respiration
 Physiology of gas exchange..
 Transport of Oxygen & Carbon dioxide
Common application of anatomy knowledge
of the respiratory system in ICU….

 Where am I supposed to put all these ECG leads?

 Listen to the base of the lungs..where to put my
stethoscope?
 How am I going to insert this ryles tube?
 Is the ETT too deep?
 Read this CXR..is there a pneumothorax?
 Where is my swan ganz-catheter?
 Is this CVP line correctly places?
 Is this pneumonia or pulmonary oedema?
 What are the causes of hypoxemia in this patient?
 Etc..etc…
 Gross Anatomy & Microscopic Anatomy

Physiology Pathophysiology

Gross Anatomy & Microscopic Anatomy

Procedures Management
Function of the respiratory system..

 Upper airways
 Humidification of the air
 Protection of airways from fluid & solids
 Cough reflexes
 Phonation

 Lower airways
 Gas exchange
 Acid-base homeostasis
 Hemodynamic reservoir
 Metabolic function
 Endocrine function
 Immune system
Surface markings……………
Anatomy …surface markings…
Gross structure of the whole respiratory
system
Upper airway…
Nose
Nasal cavity (1)
Paranasal sinuses
Nasopharynx (2)
Mouth
Oropharynx (8)
Larynx (11-17)
larynx
Interpretation of CXR…
Lower airways…
 The tracheobronchial tree
 Terminal bronchioles
 Respiratory bronchioles
 Ending in tiny blind sacs called the
alveoli.
In all, these conducting airways divideabout 15-17 times down
to the level of terminal bronchioles, which are smallest units
that do not participate in gas exchange

 Trachea - carina - left mainstem

bronchi ( R & L )
 Which in turn branch into lobar
bronchi - segmental bronchi -
subsegmental bronchi - smaller
bronchi - bronchioles
The trachea..

 11 - 13 cm
 Cricoid cartilage to carina
 Carina highly innervated…
bronchospasm and coughing when
touched
 CXR landmarks
Bronchi…
 R & L aminstem bronchi has
interesting anatomy
 R is shorter, less acute angle, R
upper lobe bronchi arising very
shortly after carina..
 Clinical importance ?
A progressive dichotomous branching
of bronchi and bronchioles occur
As we travel deeper into the respiratory system…
Respiratory epithelium
 Prepare and condition the inhaled
gas by filtering, warming and
humidifying ..
 Luminal surface layer is lined with a
specialized respiratory epithelium,
or pseudostratified ciliated columnar
epithelium with goblet cells
Mucous blanket & cilia
 The epithelial surface is covered by a
layer of mucous secreted by submucosal
mucous glands & goblet cells.
 Fine particles & bacteria within inhaled
gas are trapped
 Continuosly propelled by cilia toward the
pharynx by a process termed mucociliary
transport/clearance.
 Irritants such as pollution/smoking….
Site of gas exchange…acinus
Site of Gas Exchange:The Acinus
 Resp bronchioles, alveolar ducts and alveolar
sacs(alveoli) collectively constitute the pulmonary
functional unit or acinus
 Alveoli
 Enormous surface area..300 million ..tennis court
 Extensive network of capillaries
 Cell types: 2 different types of epithelial or pneumocytes
line the luminal surface of the alveolar wall
 Types I- 95% surface area
 Type II- surfactant
 Alveolar macrophages
 Pores of Kohn - collateral ventilation, prevent atelectasis
Pulmonary vasculature
 Dual blood supply:
 Bronchial vessels
 A part of systemic circulation
 Supplies bronchi and larger bronchioles

 Returns to the heart via pulmonary veins

 Pulmonary vessels
 Supplies structures distal to the terminal
bronchioles
Pulmonary vasculature…
 Function:
 Responsible for transporting deoxygenated blood form
the RV to the lings by the PA and returning oxygenated
blood to the left atrium by the PV
 Special feature…
 Great distensibility(thin walled/minimal smooth muscle)
 Low resistance & minimise RV workload
 Thin walled
 Recruitable blood vessels
 Uneven distribution of pulmonary blood flow influenced
by
 Low pressure hemodnamics
 Effects of gravity
 West’s 3 respiratory zones
West’s Respiratory Zones
 Scan….

 Zone 1 Palv> PA >PV

 Zone 2 PA > Palv > PV
 Zone 3 PA > PV > Palv
 The distribution of pulmonary blood
flow has major implications for the
matching of ventilation with
perfusion, and local mechanism
within the lungs function to ensure
optimal matching of ventilation and
perfusion to individual alveoli.
Local mechanism within the lungs function to ensure
optimal matching of ventilation and perfusion to
individual alveoli.

 Reflex changes in bronchiolar smooth

muscle tone in response to local carbon
dioxide concentration
 Reflex changes in the smooth muscle
tone of pulmonary blood vessels in
response to local oxygen concentration
 pH
 Hypoxemia
Control of respiration
 Alveolar ventilation requires a
 Rhythmic & Coordinated sequence of
events
 Involving the activity of
 Respiratory muscle(pump)
 Under the control of the CNS
 Central Respiratory Control
NPB Vagi Intact Vagi Cut
IC CP
A
Pons B
IV
C
Medulla

Spinal
Cord
 Central Chemical Control
Basilar Artery

Medulla Chemosensitive
Areas

Vertebral Artery
What control these events?
 Central Neuronal Control
 Medulla ( dorsal and ventral respiratory neuronal networks)
 Pneumotaxic center in upper pons
 Apneustic center in lower pons
 Autonomic Nervous System Control
 Sympathetic vs parasympathetic
 Bronchiolar smooth muscle, pulmonary vasculature smooth
muscle, mucous/serous glandular secretion
 Chemical Control of respiration
 Input from peripheral chemoreceptors(carotid,aortic bodies)
 Input from the central chemoreceptors

 Oxygen concentration
 Corbon dioxide concentration
 H+ ion concentration
 10

Alveolar Ventilation (1 = normal)

8

2
O
4

PC
2 pH
PO 2

0
PCO2 30 35 40 45 50 55 60 65
PO2 140 120 100 80 60 40 20 0
pH 7.6 7.5 7.4 7.3 7.2 7.1 7.0 6.9
 15 Awake normal

Alveolar Ventilation (liters/min)

Sleep

10 i on
uct
tr
o bs
n ic
h ro
C
or
ti cs
5
arc o
N
es th esia
De e p an

0
25 35 45 55 65
PaCO2
 Acute CO2 Retention
H+ No change
Chemo-
in HCO3-
receptive
cell pH

- H+
HCO3

CO2 CO2 CO2+ H2O

Smooth
CO2
Muscle
Blood ECF CSF
pH=7.40 pH=7.31
PCO2=40 PCO2=51
HCO3-=24 HCO3-=25
Proteins No Proteins
Blood CSF
Chemo-Cell

CO2 + H20 H+ + HCO3-

HCO3-
Intracellular protein buffers
cause bicarbonate to
accumulate in cells
pH

CO2

Chronic CO2 Retention

Mechanics of Pulmonary Ventilation

 Functional elastic properties of pulmonary

structures and intrapleural pressures
 Mechanics of inspiration
 Mechanics of expiration
 Compliance
 Work of breathing
 Airway resistance
Lung Volumes & Capacities
TLC IRV IC VC

VT

ERV

FRC RV

VT = Tidal Volume
IC = Inspiratory Capacity

IRV = Inspiratory Reserve Volume

ERV = Expiratory Reserve Volume

VC = Vital Capacity
RV = Residual Volume
FRC = Functional Residual Capacity

TLC = Total Lung Capacity

Alveolar Ventilation
 To maintain ABG parameters within normal physiologic range to
ensure adequate gas exchange to the tissues, a volume of gas must
be presented to the lungs that is sufficient for the necessary oxygen
uptake and carbon dioxide elimination.
 Minute ventilation VE = f X VT ( 6-8 L/min)

 Anatomical dead space ( 2 ml/kg of wasted ventilation)

 Alveolar volume ( 350 mL/breath)
 Alveolar minute ventilation VA = f X ( VT - VD )
o Total (Physiologic) Dead Space
o Alveolar dead space + anatomical dead space
o The relationship between dead space volume & depth and rate of
breathing is clinically significant.
o Rapid shallow breathing of more than 40 can seriously compromise alveolar
ventilation because patient is essentially moving ol=nly dead space gas and
the alveoli are not being ventilated.
o On the other hand , any increase in VT and reduction in the rate of breathing
will enhance alveolar ventilation.
This is how we survive with the
help of the lung and blood…
Pulmonary Gas Exchange
 Gases move between the alveolar air and blood
by passive diffusion.
 Fick’s Law: Flow is proportional to the pressure
gradient divided by the resistance multiplied by a
constant “K”. =K*(P1-P2)/R.
 Under normal conditions, blood is in contact with
the alveoli for 0.75 seconds, and PO2 reaches
equilibrium in about 0.25 seconds; therefore, O2
is not diffusion limited.
 If alveolar PO2 is low or the diffusion resistance is
high, capillary PO2 may not reach equilibrium with
alveolar PO2.
Oxygen Transport

 The amount of oxygen that can dissolve in blood

depends on PO2 and solubility. CO2 = SO2 * PO2.
 Solubility = 0.003 ml O2 / 100 ml blood / mmHg
(Vol. %).
 If PO2 = 100 mmHg, then blood will carry 0.3 Vol
% O2. This is too little to support metabolism.
 Each hemoglobin molecule can carry 4 molecules
of O2. Fully saturated hemoglobin can carry 1.36
ml O2 / g Hb. Normal human blood contains 15 g
Hb / 100 ml blood. 1.36 * 15 = 20.4 ml O2 / 100
ml blood.
 Hemoglobin Dissociation Curve
 The position of the dissociation curve is described by
the P50 (the pressure required to produce 50%
saturation).
 High PCO2, low pH, high temperature, and high 2,3-
DPG move the curve to the right (high P50). The
opposite conditions will cause the curve to shift to
the left.
 A high P50 indicates low affinity and a low P50
indicates high affinity.
 Anemia (low Hb concentration) reduces the amount
of O2 in blood leaving the lung, but not the level of
saturation.
 Hemoglobin has an affinity for carbon monoxide 250
times greater than for oxygen.
VENTILATION /PERFUSION RELATIONSHIP

 V/Q RATIO
 A-a GRADIENT
 Ventilation/Perfusion Inequality
 The rate of uptake of oxygen depends on the rate at
which it is supplied (ventilation), and the rate at
which it is removed (perfusion).
 If all alveoli have the same  ratio, capillary PO2 will
reach equilibrium with alveolar PO2, and there will be
no alveolar-arterial PO2 difference.
  heterogeneity leads to an alveolar-arterial
difference. That is, some alveoli may be hypo-
hyper-ventilated and others may be hypo- hyper-
perfused.
 If you give a person who has a  imbalance 100%
O2 to breathe, the alveolar arterial difference
disappears.
 Shunts
 In an ideal lung, PaO2 and PaCO2 = PAO2 and PACO2.
 In normal healthy people, these values are close but
not identical.
 In disease conditions, the numbers can vary greatly.
 The word “shunt” refers to blood that has not
exchanged gases that mixes with blood that has
exchanged gases.
 Sources of shunt:
 Thebesian circulation that perfuses the left ventricle then
dumps into the left ventricle. Bronchial circulation that
perfuses lung tissue and empties into the pulmonary
vein. In normal people this accounts for about 2-4% of
total blood flow. Perfusing collapsed alveoli or having a
hole in the wall of the atria or ventricles will produce a
right to left shunt.
 Determination of Shunt Fraction
 Shunt Equation: =(CcO2-CaO2)/(CcO2-CvO2)
 If alveolar capillary content is 20 vol%, arterial content
is 18 vol% and mixed venous content is 13 vol%, what
percentage of blood is shunted past the lung?
 Approximately 29%.
 There is a simple clinically useful way to estimate the
shunt fraction.
 Give the patient 100% O2 to breathe (FIO2=1), then
measure arterial PO2. There is approximately a 1%
shunt for every 20mmHg difference between arterial
and alveolar PO2.
 At sea level PAO2 = 760 - 47 - 40 = 673 when FIO2 = 1.
 In this example, if arterial PO2 = 470 mmHg, there is an
approximate 10% shunt.
 CO2 Transport
 Carbon dioxide is carried in the blood in three forms:
 Dissolved CO2 represents only about 6% of the total.
 CO2 content = 0.072 * PCO2 (24 times more soluble
than O2).
 Carbamino compounds represent another 4%.
 CO2 binds reversibly to the amino terminus of alpha
and beta chains.
 The remainder is carried as bicarbonate.
 CO2 + H2O <=> H2CO3 <=> H+ + HCO3-.
 In a normal individual, arterial and alveolar P CO2 are
virtually identical. Arterial PCO2 is a balance between
CO2 production and elimination.
 Solutions Containing CO2
 CO2 + H2O <=> H2CO3 <=> H+ + HCO3-
 H+ + buffer- <=> bufferH
 When CO2 combines with water, hydrogen
ions are produced. In the presence of a
buffer, a significant portion of those H+ ions
are bound. Removing product in a chemical
reaction drives the reaction to produce more
product. HCO3- is one of the products and its
concentration will increase.
Site of gas exchange…the acinus
 a-v O2 Content Difference
20 ml / 100 ml 15 ml / 100 ml

5 ml / 100 ml
 If arterial blood contains 200 ml O2 / liter blood, and
blood flow is 5 liters blood / min, then O 2 is being
supplied to tissues at 1000 ml O2 / min.
 If metabolic rate is 250 ml O2 / min, then O2 is
moving in the venous blood at 750 ml O2 / min.
 Venous O2 content is 150 ml O2 / liter blood.
(750 ml O2 / min) / (5 liters blood / min)
….