17. Terminal bronchioles have a
Broncioles branch many diameter of 0.5-1mm in
times and each division diameter.
produces tubules which are They are too thick for air
smaller exchange and considered to
be the last of the conducting
zone structures
18.
19. Type I cells account for gas
exchange.
Type II cells secrete surfactant
20. Functions of the lung
• Main function is gas exchange
– Allow passage of O2
– Allow removal of CO2
21. Functions of the lung
• Metabolic functions
– Surfactant synthesis
– Protein synthesis
– Metabolism of vasoactive substances
• ACE/Bradykinins
• Blood reservoir
– Volume = 450mls
• Allows phonation
22. Functions of the lung
• Heat exchange
• Immunological
– Alveolar macrophages
– IgA production
– Mucociliary escalator
23. Ventilation Mechanics
How air gets to the alveoli.
Gas Exchange
How gas crosses the
blood gas interface.
Gas Transport
How they are carried
around the body.
24. Ventilation Mechanics
How air gets to the alveoli.
Muscles
Diaphragm
Inspiration External Intercostal Muscles
Accessory muscles
Abdominal Muscles
Expiration
Internal Intercostal muscles assist
25. Ventilation Mechanics
How air gets to the alveoli.
Forces acting on the
lung
Elastic Tissue
Elastic tissue of
lungs is stretched
under normal
conditions.
Resulting tension
acts as a force
pulling inwards on
visceral pleura
As chest wall and diaphragm
pull on outwards on parietal
pleura causing a negative
pressure in interpleural
space. This keeps the lungs
inflated
26. Ventilation Mechanics
How air gets to the alveoli.
Airway Resistance Lung Compliance
If radius halved then resistance increases the slope of the pressure-volume curve at a
16 fold particular lung volume
=> i.e. volume change per unit of pressure
Chief site of airway resistance is the medium change (mL/cmH2O)
sized bronchi. normal value = 200mLs/cmH2O
Peripheral airways contribute little resistance Lower compliance = more effort of breathing
Considerable small airway disease can
be present before being detected in
pressure changes. Posture affects lung volume, therefore
compliance
Factors determining Disease states
Lung volume Asthma leads to hyper-inflation
Bronchi supported by surrounding Fibrosis, collapse and consolidation all
tissue decrease distensibility
Their calibre is increased as the lung Emphysema increases compliance
expands
So as lung volume is reduced
resistance is increased
Contraction of bronchial smooth muscle
27. Ventilation Mechanics
How air gets to the alveoli.
Functional Residual Capacity
FRC- volume of gas remaining in lungs at end of FRC increases with
normal expiration Height
Changing from supine to erect
Volume of lung at which elastic forces causing Emphysema- gas trapping
recoil = thoracic chest wall forces causing
expansion FRC decreases with
Obesity
FRC = 30mls/kg = 2200 mls in supine 70kg adult Muscle paralysis and GA
Changing from supine to erect
Restrictive lung disease
Pregnancy
Raise intra-abdominal pressure
28. Gas Exchange
How gas crosses the
blood gas interface.
Rate of diffusion is:
Directly proportional to cross
sectional area across which
diffusion occurs
Inversely proportional to the
thickness of the membrane
Directly proportional to the
partial pressure of the gas
across both sides
29. Gas Exchange
How gas crosses the
blood gas interface.
The amount of time that blood is in contact with
the alveolus also influences gas exchange.
The speed of blood flow past the alveolus is:
0.75 seconds under normal conditions
0.25 seconds with heavy exercise
30. Gas Exchange
How gas crosses the
blood gas interface.
Ventilation-
Pleural pressure are higher
at the bases of the lungs.
So they receive 4 times
more ventilation than
apices.
Circulation-
Low pressures in pulmonary
circulation are affected by
gravity
Bases of upright lungs
receive 20 times more blood
flow than apices.
32. Respiratory Examination
• Common Problems- Asthma.
– Baseline control
• Usual exercise tolerance
• Frequency of attacks
• Best Peak expiratory flow rate
• Usual precipitating factors
• Medication
• Usual response to therapy
• Previous hospital/ITU admissions
• Symptoms suggestive of poor baseline control
Jonathan Downham 2010
33. Respiratory Examination
• Common Problems – Asthma
– Drug History
• Do they have a nebuliser at home?
• Do they use a bronchodilator?
• Do they take theophylline or aminophylline?
(bronchodilators).
• Do they take steroids?
• Are they on medication which aggravates the
symptoms... Beta blockers, aspirin.
• Demonstrate inhaler technique.
Jonathan Downham 2010
34. Respiratory Examination
• Common Problems – Chronic Obstructive
Pulmonary Disease (COPD)
– Detailed history
• Time course
• Treatment given and effects
• Any hospital admissions in the last year
• Baseline function
• Chronically deteriorating exercise tolerance.
• Quantify normal amounts of sputum
Jonathan Downham 2010
35. Respiratory Examination
• Common Problems – Chronic Obstructive
Pulmonary Disease (COPD)
– Past Medical History
– Drug History
– Social History
– Review of systems.
Jonathan Downham 2010
36. Respiratory Examination
• Common Problems – Chest Infection
– History
• Cough
• Sputum Production
• Dyspnoea
• Wheeze
• Pleuritic chest pain
• Fever.
– Drug History.
Jonathan Downham 2010
Notas do Editor
Conducting zone allows movement of air in and out of lungsRespiratory zone allows diffusion of oxygen and carbon dioxide across capillary membranes
Larynx is a short 1.5 inch tube located in the throat below the base of the hyoid bone and tongue and oesophagusIn its walls it has supportive cartliges, interconnecting ligaments, intrinsic and extrinsic muscles and a mucosal lining.Its primary function is to provide a carefully guarded pathway between the pharynx and the trachea
9 laryngeal cartlidges2 sets of musclesIntrinsic muscles control the voiceExtrinsic muscles adjust the position of the larynx during swallowing
Thyroid cartlidge consists of two plates of hyaline cartlidge arranged in a wedge shape. These plates are fused along the anterior edge.At the top of the fused border the cartlidge extends anteriorly forming the laryngeal prominence or Adams appleHyoid bone serves as an attachment for the tongue muscles
Laryngeal muscles can adjust the size of the glottic openingThe glottis expands into a triangular shaped opening when breathingTo make sounds the laryngeal muscles reduce the size of the opening
Trachea is 4-5 inch vertical tube anterior to the oesophagusHas a wide lumen 1 inch to conduct air between the larynx and the primary bronchiEmbedded in the wall are tracheal rings made of hyaline cartlidge
4 Distinct layersMucosa with goblet cellsSubmucosa with blood vessels, neurons and glands which secrete combination of water and mucus to the surface of the tracheaCartilagionous layer containging C shaped ringsTrachealis muscles contracts on coughing which narrows lumen and increases velocity of airflow.Adventitia is loose connective tissue which binds the to the oesophagus and other nearby organs
The secondary bronchi are also known as lobar bronchi as each one directly conducts air to and from one of the lungs five lobes.
Point out apex and baseLeft lung has less volume because of space taken up by the heartPoint out pleura- will talk about this on next slide
Point out Hilum and what it is
Lung lobes are divided by connective tissue walls into compartments called bronchopulmonary segmentsEach segment functions independantly and is supplied by its own tertiary bronchus, artery, lymph vessels and autonomic nerves
When two or more alveoli share the same opening to an alveolar duct they are referred to as an alveolar sac.Approx 300 million alveoli in the lungs providing massive surface area for diffusion of gases.
MusclesInspirationDiaphragmInserted into lower ribsSupplied by phrenic nerves from C3,4,5In normal breathing moves about 1cmIn forced inspiration/expiration can move about 10cmExternal intercostal musclesConnect adjacent ribsSupplied by intercostal nerves coming off at C3,4,5Paralysis does not seriously affect breathing because diaphragm is so effectiveAccessory musclesScalene- elevate first two ribsSternomastoids- elevate sternum
Inhaler Technique Scoring Prepares Device (e.g. Shakes inhaler) 1 Exhales fully 1 activates and inhales 1 holds breath for several seconds 1
Common Problems – Chronic Obstructive Pulmonary Disease (COPD)Detailed historyIn an acute exacerbation patients usually present following a cold with deterioration of dyspnoea in association with a productive cough and discoloured sputum.Time courseTreatment given and effectsAny hospital admissions in the last yearBaseline functionHow far can you walk?Can you climb one flight of stairs easily?Chronic bronchitisHistory of cough, productive of sputum on most days, for 3 consecutive months, for at least 2 years.Emphysema is a pathological diagnosis of dilatation and destruction of the lungs distal to the terminal bronchioles
Past Medical HistoryPrevious admissions to hospital with acute exacerbations of COPDOther smoking related illnesses (ischeamic heart disease, peripheral vascular disease, strokes, hypertension)Other causes of lung disease (occupational exposure to dust, previous TB)AsthmaDrug HistoryBronchodilatorsHome oxygenWho initiated and on what evidenceHow many hours per day is it being usedLTOT should be used for greater than 15 hours per day and its aim is to prevent cor pulmonaleCaused by increase in blood pressure in the pulmonary artery which leads to enlargement and subsequent failure of the right side of the heart.Theophyliine.. Have levels been measuredSteroidsInhaler techniqueSocial HistoryConsider all aspects of daily livingNeed to stop smoking!!
CoughDuration, productive or drySputum ProductionQuantity, colour, recent changesDyspnoeaQuantitative account of exercise tolerance at baseline and during the illnessWheezePleuritic chest painCommon feature of pneumonia- be aware of pulmonary embolusFever.If symptoms are prolonged , recurrent or associated with weight loss consider the possibility of an underlying malignancy especially if they are a smoker.