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Lung Development
Five phases:
Embryonic
Pseudoglandular
Canalcular
Saccular
alveolar

Embryonic phase
Originates in the 3-week-old embryo
Ventral diverticulum from caudal end of the

laringptracheal grovee of the foregut

Diverticulum grows caudally primitive
trachea
4th weeks: the end of diverticulum divides
two primary lung buds : 3 right, 2 left

6 thweek gestation :
Lobar buds bronchopulmonary segments
Vascular component

Pseudoglandular phase
7 th-16th weeks of gestation : pulmonary

vasculature
16 thweeks: all the bronchial airways
havebeen formed; growth occur only by
elongation and widening of existing airways
Respiratory epithelium begins to differentiate
Cilia appear in proximal airways

Develop cartilago to support airways

structures
Smooth muscle cells increase
Alteration in the development of vascular
structures, cartilago, smooth muscle
pulmonary disorders

Canalicular phase
16th 24th weeks of gestation: basic structure

of the gas-exchanging portion of the lung:

formed & vascularized
Complex irregular pattern

Terminal Sacculus phase

24th term:
Intertitial tissue : less prominent
Airspace walls : thinningf

Alveolar phase
Barrier between the gas in the alveoli & the
blood in the capillaries, 3 layer:
Processes of the type I cells
Basement membrane
Endothelial cells

Pulmonary Physiology
The first few breath:
Pulmonary arterial PO2 increase, PCO
decrease
Pulmonary vasodilatation
Vascular resistance decrease
Constriction of the ductus arteriosus
Loss of maternal PG

Clossure ductus venosus :

Umbilical blood flow stop
Systemic vascular resistance increase leftside heart pressure increase clossure foramen
ovale (right to left shunt clossure)
Fetal circulation postnatal circulation
Any disturbance/ failure of any of these events :
* persistence/ recurrence of fetal circulation
* respiratory failure

Breathing
Process complex
Contaction of inspiratory muscle negative

pressure in trachea fresh air into the lung

O2 uptake & CO2 elimination diffusion across
the ultra thin alveolar capillary membrane
Fuel the cell of body with O 2 for metabolism
Maintain appropriate acid-base status by
regulation of CO2
Disfunction in any part of this process
respiratory failure mechanical ventilatory
support

Monitoring
Non invasive:
Pulse oximetri
Capnometry
Invasive :
Arterial catheterization
Pulmonary artery catheterization

Pulse oxymetry
Advantages:
Rapid response
Non invasive
Disadvantages:
Insensitive to large changes in arterial PO 2 at the upper
end of oxygenated Hb dissociation curve
Falsely elevated SaO2 reading: presence of carboxyHb
and metHb
Physical factors : poor peripheral perfusion, abnormally
thick or edematous tissue at side of sensor
nplacement, nail polish, excessive ambient light
inaccurate readings

Arterial catheterization
Advantages:
Most accurate continuous measurement PaO2
and PCO2
Disadventages:
Invasive
Involves risk of: infection, embolization,
thrombosis, ( anemia)
Need for CDH case

Mechanical ventilator
Pressure-controlled ventilation
Volume-controlled ventilation

Pressure-controlled
Advantage:
ventilation

Carefull control of PIP, mean airway pressure

avoiding barotrauma
Disadvantage:
Tidal volume depend of inspiratory time and
compliance when lung compliance changes
during the course of illnesstidal volume
may change dramatically ( avoid
undervantilation as compliance worsens or
overdiatention/ barotrauma as compliance
improves)

Volume-controlled
ventilation
Advantage:
Consistent delivered tidal volume

Disadvantages:
Actually volume gas injected into ventilator
circuit not volume of gas deliverd into the
patient lung
Humidification, compression of gas, distention
of the compliant circuit, leak around uncuffed
endotracheal tube contribute in accurate
control of delivered tidal volume.

Modes of ventilation
Control Mode
Assist-Control Mode
Intermittent Mandatory Ventilation
Synchronized Intermittent Mandatory ventilation
Pressure Support Ventilation
Continuous Positive Airway Pressure and

Positive End-Expiratory Pressure

Inverse Ratio ventilation
High-frequency Ventilation

Adjuncts to mechanical
Ventilation

Prone positioning
Inhaled nitric oxide
Pharmacologic in ARDS: PgE, acetylcysteine,
high-doses Cortx, surfactan

Management of Respiratory
Failure

Inadequate oxygenation leading to hypoxemia

or
Inadequate ventilation leading to hypercarbia
First step:
Establish an adequate airway, oxygenated
Still inadequateendotracheal tube :
16+age of child
4

The goal of mechanical

Ventilation
Restore alveolar ventilation and oxygenation

toward normal without causing injury from

barotrauma or oxygen toxicity
Maintaining PaO2 50-80mmHg
PaCO2 40-60 mmHg
pH 7,35-7,45
Mixed venous oxygen saturation <70%

Ventilator setting
Initial Pressured-cycled ventilator:
FiO2= 100%
Rate 20-30 breaths /mnt
PIP=20-30 mmHg
PEEP= 3-5mmHg
Inspiratory ratio=1:2
Initial tidal volume 6-8 ml/kg

Weaning
Process during which mechanical ventilation

slowly withdrawn, allowing the patient to assume

an increasing amount of work of breathing.
Hemodynamically stable
Spontaneously maintain an acceptable PaCO 2
FiO2 < 0,4
PIP < 30
PEEP < 5
Ventilator assisted breaths < 15x/mnt
Ratio of dead space gas/tidal volume< 0,6

(normal O,3)

Complication of Mechanical
ventilation

Barotrauma
Oxygen toxicity
Bronchopulmonary dysplasia
Nosocomial pneumonia
..... Deep Vein Thrombosis
pulmonary emboli
laringeal trauma
trachea stenosis
sinusitis

Thanks