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The Nose
Air enters the respiratory system:
through nostrils or external nares into nasal vestibule
Nasal hairs:
are in nasal vestibule are the first particle filtration system
divides nasal cavity into left and right Superior portion of nasal cavity is the olfactory region: provides sense of smell Mucous secretions from par nasal sinus and goblet cells: clean and moisten the nasal cavity
Lined by ciliated mucosal layer
Epistaxis
Most common site Littles area Situated anterior inferior part of nasal septum. Anastomosis of 4 arteries, anterior ethmoidal, septal branch of superior labial, septal branch of sphenopalatine and greater palatine. Woodruff area, anastomosis of sphenopalatine artery and posterior pharyngeal artery causes posterior epistaxis
Air Flow
Meatuses
Constricted passageways that produce air turbulence:
warm and humidify incoming air trap particles
The Palates
Hard palate:
forms floor of nasal cavity separates nasal and oral cavities
Soft palate:
extends posterior to hard palate divides superior nasopharynx from lower pharynx
Nasal Cavity
The Nasopharynx
Superior portion of the pharynx Contains pharyngeal tonsils and openings to left and right auditory tube Pseudo-stratified columnar epithelium The Oropharynx Middle portion of the pharynx Communicates with oral cavity Stratified squamous epithelium The Laryngopharynx Inferior portion of the pharynx Extends from hyoid bone to entrance to larynx and esophagus
Air flow from the pharynx, enters the larynx: a cartilaginous structure that surrounds the glottis
ANATOMY OF LARYNX
ANATOMY OF LARYNX
The Epiglottis
Composed of elastic cartilage Ligaments attach to thyroid cartilage and hyoid bone
Cartilage Functions
Thyroid and cricoid cartilages support and protect:
the glottis the entrance to trachea
During swallowing:
the larynx is elevated the epiglottis folds back over glottis
3 pairs of Small Hyaline Cartilages of the Larynx arytenoid cartilages, corniculate (Santorini) cartilages and Cuneiform (Wrisberg) cartilages
Cartilage Functions
Corniculate and arytenoid cartilages function in: opening and closing of glottis production of sound
The Glottis
Vestibular Ligaments
Speech
Speech intermittent release of expired air while opening and closing the glottis Pitch determined by the length and tension of the vocal cords Loudness depends upon the force at which the air rushes across the vocal cords The pharynx resonates, amplifies, and enhances sound quality Sound is shaped into language by action of the pharynx, tongue, soft palate, and lips
Laryngeal paralysis
UNILATERAL
Cords remain in median or para-median position Asymptomatic UNILATERAL Ipsilateral cricothyroid muscle and anaesthesia of larynx above the vocal cord Asymptomatic
RLN
BILATERAL
Cords remain in median or para-median position Dyspnoea and stridor, voice good
SLN
BILATERAL Both cricothyroid muscle paralysis and anaesthesia of upper larynx Aspiration of food and weak voice
COMBINED
UNILATERAL
Cord remains in cadaveric position, 3.5 mm from midline and unilateral paralysis of all muscle except interarytenoid Hoarsness of voice, aspiration and ineffective cough
BILATERAL
All laryngeal muscle paralysed, both vocal cord lie in cadaveric position and total anaesthesia of larynx Aphonia, aspiration, inability to cough, bronchopneumonia
Transitional portion the respiratory bronchioles and alveolar ducts Respiratory portion:
the alveoli and alveolar sac
Alveoli
Are air-filled pockets within the lungs
where all gas exchange takes place
The Trachea
Extends from the cricoid cartilage into mediastinum
Formed of rings of cartilages, incomplete posteriorly Lined by ciliated columnar epithelium It bifurcates into right and left main bronchi at the level of T5
The Right Primary Bronchus Is larger in diameter and shorter (2.5 cm) than the left Descends at a steeper angle (25) The Left Primary Bronchus Is narrower and longer (5cm) Descends at broader angle (55)
Bronchi subdivide into secondary bronchi, each supplying a lobe of the lungs Air passages undergo 23 orders of branching in the lungs Tissue walls of bronchi mimic that of the trachea As conducting tubes become smaller, structural changes occur
Cartilage support structures change Epithelium types change
Secondary Bronchi
Branch to form tertiary bronchi, also called the segmental bronchi Each segmental bronchus:
Supplies air to a single bronchopulmonary segment
The right lung has 10 The left lung has 8 or 9
Bronchial Structure
The walls of primary, secondary, and tertiary bronchi:
contain progressively less cartilage and more smooth muscle increasing muscular effects on airway constriction and resistance
The Bronchioles
Each tertiary bronchus branches into multiple bronchioles
1 tertiary bronchus forms about 6500 terminal bronchioles
Bronchiole Structure
Bronchioles:
have no cartilage are dominated by smooth muscle
Autonomic Control
Regulates smooth muscle:
controls diameter of bronchioles controls airflow and resistance in lungs
Bronchodilation
Dilatation of bronchial airways Caused by sympathetic ANS activation Reduces resistance
Bronchoconstriction
Constricts bronchi Caused by:
parasympathetic ANS activation histamine release (allergic reactions)
Pulmonary Lobules
Are the smallest compartments of the lung Are divided by the smallest trabecular partitions (interlobular septa) Each terminal bronchiole delivers air to a single pulmonary lobule Each pulmonary lobule is supplied by pulmonary arteries and veins
Exchange Surfaces
Within the lobule:
each terminal bronchiole branches to form several respiratory bronchioles, where gas exchange takes place
Alveolar Organization
Respiratory bronchioles are connected to alveoli along alveolar ducts Alveolar ducts end at alveolar sacs: common chamber connected to many individual alveoli
An Alveolus
Has an extensive network of capillaries Is surrounded by elastic fibers
Alveolar Epithelium
Consists of simple squamous epithelium Consists of thin, delicate Type I cells Patrolled by alveolar macrophages, also called dust cells Contains septal cells (Type II cells) that produce Surfactant- an oily secretion which
Contains phospholipids and proteins Coats alveolar surfaces and reduces surface tension
Lung Shape
Right lung:
is wider is displaced upward by liver
Left lung:
is longer is displaced leftward by the heart forming the cardiac notch
Pleural fluid:
lubricates space between 2 layers
Pulmonary veins carry oxygenated blood from respiratory zones to the heart
Bronchial veins anastomose with pulmonary veins Pulmonary veins carry most venous blood back to the heart
Pulmonary Circulation
Thin walled vessels at all levels. Pulmonary arteries have far less smooth muscle in the wall than systemic arteries. Consequences of this anatomy- the vessels are:
Distensible. Compressible. Low intravascular pressure.
Effect on PVR
Increase
mechanisim
Lengthening and Compression
Lung Volume
(below FRC)
Increase
Decrease
Parasympathetic innervation Acetylcholine - adrenergic agents PGE1 Prostacycline Nitiric oxide
Endothelin
Angiotensin Histamine
Alveolar hypoxemia
Bradykinin
Regulation of breathing
Medullary rhythmicity center
Nerves extend to intercostals and diaphragm Signals are sent automatically Expiratory center is activated during forced breathing
Pneumotaxic area
Controls degree of lung inflation; inhibits inspiration
Apneustic area
Promotes inspiration
Chemoreceptors
Breathing can be controlled voluntarily, up to a point Too much CO2 and H+ will stimulate inspiratory area, phrenic and intercostal nerves Central chemoreceptors: medulla oblongata monitors CSF
Peripheral chemoreceptors
Aortic bodies (vagus nerve) Carotid bodies (glossopharyngeal nerve) Respond to fluctuations in blood O, CO2 and H levels Rapid respond Pulmonary stretch receptors prevent over inflation of lungs (promote expiration)
Pulmonary ventilation
Inhalation:
always active
Exhalation:
active or passive
2. 3.
2. Abdominal muscles:
compress the abdomen force diaphragm upward Forcefully contracts while coughing and sneezing
Inspiration
Expiration
Ventilation
Depends on
Lung volume Alveolar ventilation Anatomic and physiological dead space Regional difference in ventilation
Lung volume
Total lung volume is divided into a series of volumes and capacities useful in diagnosis in pulmonary function tests
4 Pulmonary Volumes
1. Resting tidal volume:
3. Residual volume:
Alveolar Ventilation
Amount of air reaching alveoli each minute Calculated as: AV= RR X (TV DV) = 12 X (500-150) = 4200 ml/min Alveoli contain less O2, more CO2 than atmospheric air:
because air mixes with exhaled air
Dead space
Anatomical
Volume of conducting airway Its about 150ml
Physiological
Volume of gas that does not eliminate CO Volume is same as above It is increased in many lung disease
Mechanics of breathing
Depends on Pressure volume curve Compliance
Lung volume at any given pressure is slightly more during deflation than it is during inflation, it is called Hysteresis (due to surface tension)
Compliance
An indicator of expandability V/P (200 ml/ cm HO) Low compliance requires greater force High compliance requires less force
Deformity of thorax
Ossification of costal cartilages Paralysis of intercostal muscles Blockage of smaller air way
Surface tension
Surfactant reduces surface tension forces by forming a monomolecular layer between aqueous fluid lining alveoli and air, preventing a water-air interface
Without surfactant smaller alveolar have increased collapse & would tend to empty into larger alveoli
Big would get bigger and small would get smaller
Resistance
Airway resistance
Or
Tissue resistance
Airway resistance
Friction is the major nonelastic source of resistance to airflow The relationship between flow (F), pressure (P), and resistance (R) is:
P F=R
The amount of gas flowing into and out of the alveoli is directly proportional to P, the pressure gradient between the atmosphere and the alveoli
Gas flow is inversely proportional to resistance with the greatest resistance being in the medium-sized bronchi
As airway resistance rises, breathing movements become more strenuous Severely constricted or obstructed bronchioles:
Can prevent life-sustaining ventilation Can occur during acute asthma attacks which stops ventilation
Epinephrine release via the sympathetic nervous system dilates bronchioles and reduces air resistance
Tissue resistance
Due to tissue displacement during ventilation (lungs, thorax, diaphragm) It is the 20% of total resistance Mainly from lung tissue resistance and chest wall resistance Air flow resistance is around 1 cm HO/L/sec Increases up to 5 folds in obstructive lung disease by obesity, fibrosis, ascites
Work of breathing
Done by respiratory muscles to over come elastic and frictional forces opposing inflation.
W= F X S ( force X distance) = P X V = area under P-V curve
Normal breathing
active inhalation passive exhalation (work of exhalation recovered from potential energy stored in expanded lungs & thorax during inspiration)
Area 1 = work done against elastic forces ( compliance) = 2/3 Area 2 = work done against frictional forces ( resistance work) =1/3 Area 1+2 = total work done = 2/3 + 1/3 = 1
TV elastic component of work RR ( flow) frictional work People with diseased lungs assume a ventilatory pattern optimum for minimum work of breathing. COPD/Obstructive disease-Slow breathing with pursed lips( frictional work) Fibrosis/Restrictive disease-Rapid shallow breathing(elastic work)
References
Millers Anesthesia- Ronald D. Miller 7th edition Respiratory physiology- John B. West, 8th edition A Practice of Anesthesia- Wylie and Chuchill Davidson, 5th edition
www.anaesthesia.co.in