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Ubaidur Rahaman
Senior Resident,
CCM,
SGPGlMS,
Lucknow, lndia
COPD is a disease of resistance during expiration
but
with the consequence of restriction during inspiration.
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Pressure Volume relationship
of of
respiratory system
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
50
75
100
Chest wall
Lung
Chest wall and Lung
( respiratory system)
V
i
t
a
l

c
a
p
a
c
i
t
y

%
TLC
P-V curve of Lung, Chest wall and Respiratory system
0
25
50
0
-20 20
FRC
RV
Pressure ( cm H2O)
Ppl, Pcw, Prs
V
i
t
a
l

c
a
p
a
c
i
t
y

%
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Resting Volume of Respiratory system
At End Expiration
Elastic force of LUNG Elastic force of CHEST WALL
=
Functional Residual Capacity
(FRC)
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
5.0
2.5
3.0
IRV
IC
VC
TLC
TV
LUNG VOLUMES
0
2.5
1.25
TLC
RV
ERV
FRC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Pressure, Volume and Flow
relationship
of Respiratory system
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Relationship between intrathoracic pressures
TPP = PA Ppl
TPP = Transpulmonary Pressure
PA = Alveolar Pressure
Ppl = Pleural Pressure
Pel = lung elastic recoil pressure
PA = Ppl + Pel
TPP = (Ppl + Pel) (Ppl) = Pel
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Relationship between intrathoracic pressures
TAP = Paw Ppl TAP = Paw Ppl
TAP = Transairway Pressure
Paw = airway pressure
Ppl = Pleural Pressure
TPP
TAP Paw
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-5 -5
0
End expiration
PA = 0
TPP = PA Ppl
0
-5 -5
Ppl = -5
TPP = 0 (-5) = +5
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-7 -7
0
Beginning of inspiration
TPP = PA Ppl
Ppl = -7
+5 = PA (-7)
-2
-7 -7
+5 = PA (-7)
PA = +5 7 = -2
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-7 -7
0
Mid inspiration
-1
-7 -7
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-7 -7
0
End inspiration
TPP = PA Ppl
Ppl = -7
TPP = 0 (-7)
0
-7 -7
TPP = 0 (-7)
TPP= +7
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-5 -5
0
Beginning of passive expiration
TPP = PA Ppl
Ppl = -5
+7 = PA (-5)
+2
-5 -5
+7 = PA (-5)
PA = +2
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-5 -5
0
Mid expiration
TPP = PA Ppl
PA = +1
TPP = +1 (-5)
+1
-5 -5
TPP = +1 (-5)
PA = +6
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-5 -5
0
End expiration
TPP = PA Ppl
PA = 0
TPP = 0 (-5)
0
-5 -5
TPP = 0 (-5)
TPP = +5
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
TPP and TAP remains positive TPP and TAP remains positive
Throughout the respiratory cycle Throughout the respiratory cycle
In healthy lung during normal tidal respiration In healthy lung during normal tidal respiration
keeping the alveoli and airways keeping the alveoli and airways
patent patent
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
+10 +10
0
Beginning of forced expiration
TPP = PA Ppl
Ppl = +10
+7 = P (+10))
+10
+8
+6
+4
+2
+17
+10 +10
+7 = PA (+10))
PA = +17
+15
+13
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
+10 +10
0
forced expiration
+10
+8
+6
+4
+2
TAP = Paw Pp
TAP = (+10) ( +10) = 0
+17
+10 +10
+15
+13
Dynamic airway Collapse ( DAC)
Expiratory Flow Limitation
Equal Pressure Point ( EPP)
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Equal Pressure Point ( EPP)
Point in airway where TAP is zero during expiration
Dynamic Airway Collapse
Point in airway distal to EPP, TAP becomes negative,
causing airway to collapse
No amount of effort will increase the expiratory flow
Expiratory Flow limitation
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
First 11 generation of airway ( bronchi)
supported by cartilage ring/ plates
Counter balance of Dynamic Airway Collapse
12
th
generation and beyond ( bronchioles)
supported by tethering effect of elastic recoil of surrounding lung parenchyma
cartilagenous support in bronchi
Lung volume in bronchioles
Patency of airways is a function of
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Equal Pressure Point
Dynamic point
As airway resistance increases
or
Lung volume decreases
Moves closer to Alveoli
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
+10 +10
0
+10
+8
+6
+4
+2
+2
+4
+6
+10 +10
0
FORCED EXPIRATION
+17
+10 +10
+15
+13
Beginning of forced expiration
+10 +10
+12
+10
Mid forced expiration
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Airway disease
COPD, Asthma
Destruction of cartilage of airway
can be a manifestation of
Expiratory Flow Limitation
Lung parenchyma disease
leading to reduced lung volume
collapse, lung destruction, pneumonectomy
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
There is no dynamic airway collapse
No expiratory flow limitation
IN HEALTHY LUNG
During quiet breathing
Because of invagination of posterior membrane of tracheo bronchial tree
During forced expiration
Small degree of dynamic airway collapse can occur
(Upto 40% reduction in cross sectional area of airway)
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Dynamic airway collapse during Coughing
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Flow and Time Relationship
Of
Respiratory system
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Concept of
Closing Volume & Closing Capacity Closing Volume & Closing Capacity
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Effect of gravity
+
weight of lung
Vertical gradient
in in
Ppl and TTP
Dependent alveoli have lesser volume
than non dependent alveoli
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
PLEURAL PRESSURE AND TPP GRADIENT
(At FRC)
BODY
POSITION
TOP OF
LUNG
BOTTOM OF
LUNG
Ppl TPP Ppl TPP
-8 8 -2 2
UPRIGHT
-8 8 -2 2
SUPINE
-4 4 0 0
PRONE
-3.5 3.5 0 0
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
P- V curve of Respiratory system at different Lung volumes
VERTICAL GRANIDIENT
FRC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
TLC
P- V curve of Respiratory system at different Lung volumes
VERTICAL GRANIDIENT
RV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
IN HEALTHY LUNG
During forced expiration
Dynamic airway collapse occurs
starting from dependent lung regions
Critical volume of lung during expiration to prevent dynamic airway collapse
CLOSING CAPACITY
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
5.0
2.5
3.0
CLOSING CAPACITY
TLC
In healthy lung
44 years
CC= FRC in supine position
66 years
CC = FRC in upright position
CC
0
2.5
1.25
RV
CC
FRC
Smoking, ageing, obesity,
supine position
Increases CC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
5.0
2.5
3.0
Effect of PEEP on CLOSING CAPACITY
CC
TLC
PEEP
0
2.5
1.25
RV
FRC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
TIME CONSTANT
length of time required to fill or empty lung units length of time required to fill or empty lung units
Alveoli = compliance
Function of
Airway= resistance
TC = C R
1 TC = 63% of lung unit fill/ empty
3 TC = 95%
5 TC = 99%
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
normal
Decreased compliance
Increased resistance
TC
TC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Obstructive Airway Disease Obstructive Airway Disease
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increased Airway Resistance
dynamic airway collapse dynamic airway collapse
Expiratory Flow Limitation Expiratory Flow Limitation
Air Trapping Air Trapping
DYNAMIC HYPERINFLATION
(DHI)
Increased End Expiratory Lung Volume ( EELV)
Air Trapping Air Trapping
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
v
T
FRC
DHI is probably an adaptive response to overcome DAC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increases elastic recoil of lung ---- opens airway---- improves expiratory flow
Initially DHI
Increases elastic recoil of lung ---- opens airway---- improves expiratory flow
But
Comes
At
price
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
V
TLC
TV
IRV
IC
P-V CURVE OF RESPIRATORY SYSTEM
Healthy lung- tidal ventilation
P
RV
FRC
TV
ERV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
V
TLC
TV
IRV
IC
P-V CURVE OF RESPIRATORY SYSTEM
Healthy lung - exercise
P
RV
FRV
TV
ERV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
V
TLC
TV
IRV
IC
P-V CURVE OF RESPIRATORY SYSTEM
Chronic obstructive airway disease- tidal breathing
P
RV
EELV
TV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
V
TLC
IC
EELV
IRV
P-V CURVE OF RESPIRATORY SYSTEM
Chronic obstructive airway disease- exacerbation
P
RV
EELV
EELV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increased EELV Increased EELV
More Zone I and II formation More Zone I and II formation
Increased dead space Increased dead space
EFFECT ON GAS EXCHANGE
V/Q mismatch
Increased minute ventilation requirement
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Displacement of respiratory system towards upper flatter portion of P Displacement of respiratory system towards upper flatter portion of P- -V curve V curve
Altered geometry of the chest wall Altered geometry of the chest wall
Flattened and lowered diaphragm, more horizontal rib cage Flattened and lowered diaphragm, more horizontal rib cage
EFFECT ON DYNAMIC MECHANICS
Respiratory muscles operating at higher lung volumes Respiratory muscles operating at higher lung volumes
Increased elastic loading of inspiratory muscles at end expiration Increased elastic loading of inspiratory muscles at end expiration
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Expiratory muscles axis of contraction is altered Expiratory muscles axis of contraction is altered
EFFECT ON DYNAMIC MECHANICS
Before starting inspiratory flow must overcome this increased elastic load Before starting inspiratory flow must overcome this increased elastic load
Effort required to generate tidal volume is more than the muscle can Effort required to generate tidal volume is more than the muscle can
generate at that lung volume generate at that lung volume
Expiratory muscles axis of contraction is altered Expiratory muscles axis of contraction is altered
paradoxical indrawing of lower ribs paradoxical indrawing of lower ribs hoover sign hoover sign
Decreased ventilatory capacity
Functional muscle weakness and fatigue
Increased WOB
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increased EELV Increased EELV
Increased TPP Increased TPP
preload and preload and afterload of RV afterload of RV
Increased ventilatory drive Increased ventilatory drive
More negative pleural pressure More negative pleural pressure
RV preload in face of RV preload in face of RV afterload RV afterload
EFFECT ON HEMODYNAMICS
Series ventriclular interdependence Series ventriclular interdependence
LV stroke volume
Hypotension
Parallel ventricular interdependence
LV filing compromised
LV dysfunction and failure
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increased Increased
ventilatory drive ventilatory drive
EFFECT ON PATIENT
anxiety anxiety
Worsening Worsening
hemodynamics hemodynamics
Increased Increased
WOB WOB
Neuromechanical Neuromechanical
discoupling discoupling
VQ mismatch VQ mismatch
dyspnoea
Neural drive= Increased RR = decreased expiratory time Neural drive= Increased RR = decreased expiratory time
Expiratory flow limitation = need for increased expiratory time Expiratory flow limitation = need for increased expiratory time
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
+4 +4
0
+2
+2
+4 +4
0
forced expiration
( obstructive airway disease)
+5
+4
+3
+6
+4 +4
+5
+4
+6
+4 +4
Pursed lip breathing
PEEP
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
MANAGEMENT
GOAL GOAL
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
CORRECTION OF GAS EXCHANGE
REDUCTION OF WOB
CORRECTION OF
LUNG MECHANICS
TREATMENT OF BASELINE DISEASE
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Prevention of DHI
CORRECTION OF LUNG MECHANICS
Reduce airway resistance
PPV
PEEP
Easy Inspiratory flow
Prevention of DAC
Reduce airway resistance
Treatment of disease
Prevention of DAC
Neuro muscular recoupling
sedation,anti anxiety
PPV
Adequate expiratory time
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Positive Pressure Ventilation
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
PEEP
For easy inspiration
o
+7
+10 +10
-11 -4
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
-7 -7
0
Beginning of inspiration
TPP = PA Ppl
Ppl = -7
+5 = PA (-7)
+10
-7 -7
+5 = PA (-7)
PA = +5 7 = -2
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
+4 +4
PEEP
For easy expiration
+5
+4
+3
+6
+4 +4
PEEP
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Setting total cycle time Setting total cycle time
Flow rise Flow rise
cycling cycling cycling cycling
Calculation of expiratory time Calculation of expiratory time
Calculation of TCT Calculation of TCT
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
the difficulty lies, not in new ideas,
but escaping old ones,
which ramify, for those brought up with them,
as most of us have been, into every corner of our minds.
- John Maynard Keynes
Thank you
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India