The Cardiovascular System THE HEART HEART is a hollow muscular organ that pumps blood through the body.

The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is the circulatory system's power supply. It must beat ceaselessly because the body's tissues-especially the brain and the heart itself-depend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result. The human heart is shaped like an upside-down pear and is located slightly to the left of center inside the chest cavity within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and rests on the diaphragm, approximately at the level of the fifth intercostal space. (This is exactly where one would place a stethoscope to count the apical pulse.) Its broader posterosuperior aspect, or base, from which the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib. About the size of a closed fist, the heart is made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of the body. This rhythmic contraction begins in the developing embryo about three weeks after conception and continues throughout an individual's life. The muscle rests only for a fraction of a second between beats. Over a typical life span of 76 years, the heart will beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood.

Structure of the heart

The human heart has four chambers. Two atria and two ventricles. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart's lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood away from the heart. A wall of tissue separates the right and left sides of the heart. Each side pumps blood through a different circuit of blood vessels: The right side of the heart pumps oxygenpoor blood to the lungs, while the left side of the heart pumps oxygen-rich blood to the body. Blood returning from a trip around the body has given up most of its oxygen and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into two large veins, the superior vena cava and inferior vena cava, which empty into the right atrium of the heart. The right atrium conducts blood to the right ventricle, and the right ventricle pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty into the left atrium. Blood passes from the left atrium into the left ventricle, from where it is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that branch off the aorta distribute blood to various parts of the body.

A. THE HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. TWO VALVES, known as atrioventricular valves, are located between the atria and ventricles. The AV valves prevent backflow into the atria when the ventricles contract. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. Tiny white cords, the chordae tendinae- literally, heart strings- anchor the cusps to the walls of the ventricles. When the heart is relaxed and blood is passively filling its chambers, the AV- valve flaps hang limply into the ventricles. As the ventricles contract, they press in the blood in their chambers, and the intraventricular pressure begins to rise. The other TWO HEART VALVES are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moonshaped flaps of tissue. They guard the bases of the large arteries leaving the ventricular chambers. The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. When the ventricles are contracting and forcing blood out of the heart, the cusps are forced open and flattened against the

walls of the arteries by the tremendous force of rushing blood. Then when the ventricles relax, the blood begins to flow backward toward the heart, and the cusps fill with blood, closing the valves. This prevents arterial blood from reentering the heart. Each set of valves operates at a different time. The AV valves are open during heart relaxation and closed when the ventricles are contracting. The semilunar valves are closed during heart relaxation and are forced open when the ventricles contract.

The tricuspid valve lies behind the right half of the sternum opposite the fourth intercostal space.

The mitral valve lies behind the left half of the sternum opposite the fourth coastal cartilage.

The pulmonary valve lies behind the medial end of the third coastal cartilage and the adjoining part of the sternum.

The aortic valve lies behind the left half of the sternum opposite the third intercoastal space.

B. THE MYOCARDIUM Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding of tough connective tissue to form the walls of the heart's chambers. The atria, the receiving chambers of the heart, have relatively thin walls compared to the ventricles, the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in) thick in an adult-because it must work the hardest to propel blood to the farthest reaches of the body. C. THE PERICARDIUM A tough, double-layered sac known as the pericardium surrounds the heart. The inner layer of the pericardium, known as the epicardium, rests directly on top of the heart muscle. The outer layer of the pericardium attaches to the breastbone and other

structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. D. THE ENDOCARDIUM The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white tissue known as the endocardium. The same type of tissue, more broadly referred to as endothelium, also lines the body's blood vessels, forming one continuous lining throughout the circulatory system. This lining helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. E. THE CORONARY ARTERIES The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels. Known as the coronary arteries, these blood vessels encircle the heart like a crown. About 5 percent of the blood pumped to the body enters the coronary arteries, which branch from the aorta just above where it emerges from the left ventricle. Three main coronary arteries-the right, the left circumflex, and the left anterior descending-nourish different regions of the heart muscle. From these three arteries arise smaller branches that enter the muscular walls of the heart to provide a constant supply of oxygen and nutrients. Veins running through the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium. FUNCTION OF THE HEART The heart's duties are much broader than simply pumping blood continuously throughout life. The heart must also respond to changes in the body's demand for oxygen. The heart works very differently during sleep, for example, than in the middle of a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can respond almost instantaneously to shifting situations-when a person stands up or lies down, for example, or when a person is faced with a potentially dangerous situation.

The Respiratory System

The main function of the lungs is to provide continuous gas exchange between inspired air and the blood in the pulmonary circulation, supplying oxygen and removing carbon dioxide, which is then cleared from the lungs by subsequent expiration. Survival is dependent upon this process being reliable, sustained and efficient, even when challenged by disease or an unfavourable environment. Evolutionary development has produced many complex mechanisms to achieve this, several of which are compromised by anaesthesia. A good understanding of respiratory physiology is therefore essential to ensure patient safety during anaesthesia. The respiratory tract extends from the mouth and nose to the alveoli. The upper airway serves to filter airborne particles, humidify and warm the inspired gases. The patency of the airway in the nose and oral cavity is largely maintained by the bony skeleton, but in the pharynx is dependent upon the tone in the muscles of the tongue, soft palate and pharyngeal walls.

Larynx The larynx lies at the level of upper cervical vertebrae, C4-6, and its main structural components are the thyroid and cricoid cartilages, along with the smaller arytenoid cartilages and the epiglottis, which sit over the laryngeal inlet. A series of ligaments and muscles link these structures, which, by a co-ordinated sequence of actions, protect the larynx from solid or liquid material during swallowing as well as regulating vocal cord tension for phonation (speaking). The technique of cricoid pressure is based on the fact that the cricoid cartilage is a complete ring, which is used to compress the oesophagus behind it against the vertebral bodies of C5-6 to prevent regurgitation of gastric contents into the pharynx. The thyroid and cricoid cartilages are linked anteriorly by the cricothyroid membrane, through which access to the airway can be gained in an emergency. Trachea and bronchi The trachea extends from below the cricoid cartilage to the carina, the point where the trachea divides into the left and right main bronchus, with a length of 12-15cm in an adult and an internal diameter of 1.5-2.0cm. The carina lies at the level of T5 (5th thoracic vertebra) at expiration and T6 in inspiration. Most of its circumference is made up of a series of C-shaped cartilages, but the trachealis muscle, which runs vertically, forms the posterior aspect. When the trachea bifurcates, the right main bronchus is less sharply angled from the trachea than the left, making aspirated material more likely to enter the right lung. In addition, the right upper lobe bronchus arises only about 2.5cm from the carina and must be accommodated when designing right-sided endobronchial tubes. Lungs and pleura The right lung is divided into 3 lobes (upper, middle and lower) whereas the left has only 2 (upper and lower), with further division into the broncho-pulmonary segments (10 right, 9 left). In total there are up to 23 airway divisions between trachea and alveoli.

The bronchial walls contain smooth muscle and elastic tissue as well as cartilage in the larger airways. Gas movement occurs by tidal flow in the large airways. In the small airways, by contrast, (division 17 and smaller) it results from diffusion only. The pleura is a double layer surrounding the lungs, the visceral pleura enveloping the lung itself and the parietal pleura lining the thoracic cavity. Under normal circumstances the interpleural space between these layers contains only a tiny amount of lubricating fluid. The pleura and lungs extend from just above the clavicle down to the 8th rib anteriorly, the 10th rib laterally and the level of T12 posteriorly. Blood supply The lungs have a double blood supply, the pulmonary circulation for gas exchange with the alveoli and the bronchial circulation to supply the parenchyma (tissue) of the lung itself. Most of the blood from the bronchial circulation drains into the left side of the heart via the pulmonary veins and this deoxygenated blood makes up part of the normal physiological shunt present in the body. The other component of physiological shunt is from the thebesian veins, which drain some coronary blood directly into the chambers of the heart. The pulmonary circulation is a low-pressure (25/10mmHg), low-resistance system with a capacity to accommodate a substantial increase in blood flowing through it without a major increase in pressure. Vascular distension and recruitment of unperfused capillaries achieve this. The main stimulus which produces a marked increase in pulmonary vascular resistance is hypoxia.