Structure and Function
How the Architecture 01the LungSubserves Its Function
Blood-Gas Interface
Airways and Airflow
Blood Vessels and Flow
Stability of Alveoli
Removal of Inhaled Particles
Webeginwith a short review of the refationships betweenstructure and func-
tion in the fungoFirst we look at blood-gas interface where the exchangeof the
respiratory gases occurs. Next we look at how oxygenis brought to the inter-
face throughthe airways, and thenhowthe bloodremoves the oxygen fromthe
lung. Finallytwo potential problemsof the lung are briefly addressed: how the
alveoli maintaintheir stability, andhow the lungis kept cleanin a polluted
The lung is for gas exc ha nge . Its prime funct ion is to allow oxygen to move from
the air into the venous blood and carbon dioxide [Q move out. The lung does
other jobs too. It metabolizes some compounds, filters unwanted mater ials from
the circul ation, and acts as a reservo ir for blood. But its cardinal function is to C X ~
change gas, and we shall therefore begin at th e blood-gas interface where the gas
excha nge occurs.
, i
Blood-Gas Interface
Oxygen and carbon dioxide move between air and blood by simple diffusion, that
is, from an area of high to low partial pressure, * much as water runs downhill.
Pick's law of diffusion states that the amount of gas that moves across a sheet of t is-
sue is proportional to the area of the sheet but inversely proporti onal to its thick-
ness. The blood- gas barrier is exceedingly thin (Figure I-I) and has an area of be-
tween 50 and 100 square meters. It is therefore well suited to its funct ion of gas
How is it possible to obtain such a prodi gious surface area for diffusion inside
the limited thoracic cav ity?This is done by wrapping the small blood vessels (cap-
illaries) around an enormous number of small air sacs called alveoli (Figure 1-2).
There are about 300 mill ion alveo li in the hu man lung, each abou t 1/3 mm in di-
ameter. If they were spheres," their to tal surface area woul d be 85 square meters,
but their volume only 4 liters. By contrast , a single sphere of this volume would
have an int ernal surface area of only 1/100square meter. Thus, the lung gene rates
this large diffusion area by be ing divided into myriad un its.
Gas is brought to one side of the blood-gas interface by airways, an d blood to
the othe r side by blood ,'essels.
Airways and Airflow
The a irways consist of a series of branching tubes which beco me narrower,
short er, and more numerous as they penetrat e deeper into the lung (Figure I ~ J ) .
The tracheadivides into right and left main bronchi, which in turn divide into 10'
bar , then segmental bronchi. This process continues down to the tenninal bran,
chioles, wh ich are the sma llest airways wit hout alveoli. All of these bronch i make
up the conducting airways. Their function is to lead inspired air to th e gas ex,
changing regions of the lung (Figure 1, 4). Because the conduct ing airways con,
tai n no alveo li and therefore take no part in gas exchange, the y const itute the
ana tomic dead space. Its volume is about 150 ml.
The terminal bronch ioles divide into respiratory bronchioles, whic h have occa-
sional alveoli budding from their walls. Finally, we come to the alveolar dUClS,
wh ich are completely lined with alveoli. This alveolated region of the lung where
the gas excha nge occ urs is known as the respiratory zone. The portion of lung dis,
*The part ial pressure of a gas is found by mulriplving its concentrat ion by the total pres-
sure. For example, dryair has 20.93% 0 ,. Its partia l pressure (Po) at sea level (baromet -
ric pressure 760 mm Hg] is 20.93/ 100 X 760 = 159 rom Hg. When air is inhaled into the
upper airways, it is war med and moistened, and the water vapor pressure is then 47 mm
Hg, so tha t the tot al dry gas pressure is only 760 - 47 = 713 mm Hg. The Po , of inspired
air is therefore 20.93/ 100 X 713 = 149 mm Hg. A liquid exposed to a gas unt il equili-
bration takes place has the same parti al pressure as the gas. For a more complete descrip-
t ion of the gas laws, see Appendix A.
t The al veoli are not sphe rical hut polyhedral. No r is the whole of their surface available
for diffusion (see Figure 1, 1). These numbers are therefore only approximate .
lar wat
The 1. -_
t lon), a
and a ~
Structure and Function
Figure 1-1. Elect ron micrograph showing a pul monary capill ary (C) i n the alveo-
lar wall. Note the extremel y thin blood-gas barri er of about 0.3 urn i n some pl aces.
The large arrowi ndicates t he diffusi on pat h from alveolar gas to the interior of t he
eryt hrocyte (ECI and incl udes t he layer of surfact ant (not shown in the prepara-
t ion ), alveolar epit heli um (EP), interst it ium (IN), capill ary endothel ium (EN), and
pl asma. Part s of st ructural cell s call ed fibroblasts (FBI, baseme nt membrane (8M ),
and a nucleus of an endot helia l cell are also seen.
Figure 1-2. Sect ion of lung showing many alveo li and a small bronchiole. The pul-
monary capil lar ies run i n t he wal ls of the alveoli (Figure 1-1). The holes in t he alve-
olar walls are the pores of Kahn.
Figure 1-3. Cas
awa y, al lov ' r-:;
ol es t o be s ~ ~ "
tal to a termu
tance from "
but the respir
3 li ters durine -
During i
drawn into"
tion of the J
intercost al
of the thorax. ~
flow. like war
Structure and Function 5
Figure 1-3. Cast of the ai rwa ys of a human lung. The alveoli have been pruned
away, al lowi ng t he conducti ng ai rways f rom t he trachea to the terminal bronchi-
oles to be seen.
tal to a termi nal bronc hiole forms an anatomical unit called the acinus. The dis-
ranee from the terminal bronchiole to the most distal alveolus is only a few mrn,
but the respiratory zone makes up most of the lung, its volume being about 2.5 to
3 liters dur ing rest.
During inspirati on, the volume of the thoracic cavity increases and air is
drawn into the lung. The incr ease in volume is brought about par tly by contrac-
tion of the diaphragm, which causes it to descend, and partly by the action of th e
int ercostal muscles, which raise the ribs, thus increasing the cross-sectional area
of the thorax. Inspired air flows down to about the termi nal bronchioles by bulk
flow, like water through a hose. Beyond that point , the combined cross-sectiona l

,./' r.'::
2 c
--=;Jb.: p,\
,I '

I -j
Respiratory{ J 1:



20 c >-
__ 0

c --

Figure 1-4. Ideali zat ion of th e human air wa ys according to We i bel. Not e th at th e
f i rst 16 generations (2) make up t he conducti ng airways, and t he last 7, t he respi -
rat or y zone (or the t ransitional and respir atory zone) .
area of the airways is so enormous because of the large number of branches (Fig-
ure 1-5) that the forward velocity of the gas becomes small. Diffusion of gas
within the airways then takes over as the dominant mechani sm of vent ilat ion in
the respiratory zone. The rate of diffusion of gas molecules within the airways is
so rapi d and th e distances to be covered so short that differences in concentrat ion
within the acinus arc virt ually aboli shed with in a second. However, because the
velocity of gas falls rapidly in the region of the ter mina l bronchioles, inhaled dust
frequentl y sett les out there.
• Divided into a conducting zone and a respiratory zone
• Volume of the anatomic dead space is about 150 ml
• Volume of the alveolar region is about 2.5-3.0 liters
• Gas movement in the alveol ar region is chiefly by diffusion
Figure 1· 5. a-
area of t he a'
f orward ve toer
th e resptraro
vent ilat io n.
The lunc
resting breat
ml, for ex
trast, a chi
The pres
ing normal '
the airwav-
Structure and Function 7
l' 300

t ~
200 Conducting : Respiratory
zone ----iI>:'- zone-c-s t;
<; I
100 I
,t .................. . . , . ~
0 5 10 15 20 23
Airway generation
Figure 1 ~ 5 . Di agram t o show t he ext remely rapid i ncrease i n total cross-sect ional
area of t he ai rways i n t he respi ratory zone (compare Figure 1-4). As a result, the
forward velocity of t he gas duri ng inspirati on becomes ve ry sma ll i n t he region of
the respir atory bronchi ol es, and gaseous diffusion becomes th e chief mode of
venti latio n.
The lung is elastic and returns passively to its preinspiratory volume during
restin g breat hi ng, Ir is remarkably easy to distend. A normal brearh of about 500
rnl, for example, requires a distending pressure of less than 3 em water. By con-
trast , a chi ld's balloon may need a pressure of 30 em water for the same cha nge in
The pressure required to move gas through the airways is also very small. Dur-
ing normal inspiration, an air flow rate of 1 liter/sec requires a pressure drop along
the airways of less than 2 ern water. Compare a smoker's pipe whic h needs a pres-
sure of about 500 ern water for the same flow rate.
Blood Vessels and Flow
The pulmonary blood vessels also form a series of branching tubes from the pul-
monary artery to th e capillaries and baek to the pulmonary veins. Init ially, the ar-
reries, veins, and bronchi run close together, but toward the periphery of the lung,
t he veins move away to pass bet ween the lobules, whereas the art eri es and
bronchi travel toget her down the cent ers of the lobules. The capillaries form a
dense network in the walls of the alveoli (Figure 1-6). The diameter of a capillary
, r
, ,
, .
8 Chapter 1
Figure 1-6. View of an alveolar wa ll (in t he f rog ) showi ng t he dense network of
capi ll aries. A small art ery (left) and vein (ri ght) can also be seen. The i ndi vi dual
capi l lary segments are so short that t he bl ood forms an al most cont inuou s sheet.
segment is about 10 urn, just large enough for a red blood cell. The lengths of the
segments are so short that the dense network forms an almost conr inuous sheet of
blood in the alveolar wall, a very efficient arrangement for gas exchange. Alveo-
lar walls are not oft en seen face on, as in Figure 1,6. The usual, thin microscopic
cross sect ion (Figure 1-7) shows the red blood cells in the capillaries and empha-
sizes the enormous exposure of blood to alveolar gas, with only the th in blood-gas
barrier interveni ng (compare Figure IvI},
The ext reme thinness of the blood- gas barri er means that the capillaries are
easily damaged. Increasing th e pressure in the capillaries to high levels or in-
flat ing the lung to high volumes, for example, can raise the wall st resses of th e
capillaries to the point at whic h ul trastru ctural cha nges can occur. The capil-
laries then leak plasma and even red blood cells into the alveolar spaces.
The pulmonary artery receives the whole output of the right heart , but the re-
sistance of the pulmonary circuit is astonishingly small. A mean pulmonary arte-
rial pressure of onl y about 20 ern water (about 15 mm Hg) is required for a flowof
6 liters/rum (the same flow th rough a soda straw needs 120 cm water).
Each red blood cell spends about 3/4 sec in the capillary network and during
thi s t ime probably traverses two or three alveoli. So efficient is the ana tomy for
Structure and Function 9
rk of
sheet .
jeer of

s are
- the
pi l-
Figure Microscopic section of dog l ung showi ng capi ll aries in t he alveolar
wa l ls. The bloo d-gas barr ier is so th in th at it cannot be ident ified here (compare
Figure 1 1). This sect ion was pr epared f rom lu ng t hat was rapidl y frozen whi le
i ng perfu sed,
gas exchange tha t th is brief time is sufficient for virtually complete equilibrat ion
of oxygen and carbon dioxide between alveolar gas and capillary blood.
The lung has an addit iona l blood system, the bronchial circulat ion, which sup-
plies the conducti ng airways down to about the terminal bronchioles. Some of
this blood is carried away from the lung via the pulmonary veins and some enters
the systemic circulat ion . The flow through the bronchial circulation is a mere
fract ion of that through the pulmonary circulation, and the lung can funct ion
fairly well without it, for example, fol lowing lung transplantati on.
To conclude this brief account of the functional ana tomy of the lung, let us
glance at two special problems that the lung has overcome.
Blood Vessels
• Who le of the output of the right heart goes to the lung
• Diameter of t he capillaries is about 10 ..... m
• Thickness of much of the blood-gas barrier is less than 0.3 urn
• Blood spends about 3/4 sec in the capillaries
I ~ I
j ••
Stability of Alveoli
The l ung can he regarded as a collect ion of 300 million bubbl es. each 0.3 mm in
diameter. Such a structure is inherently unstable. Because of the surface tension
of the liquid lining the alveoli , relat ively large forces develop that tend to collapse
alveoli. Fortunatel y, some oft he cells lining the alveoli secrete a material called
surfactant, whi ch dramatically lowers the surface tension of the alveolar lining
layer (see Chapter 7). As a consequence, th e stab ility of the alveoli is enor mously
increased. although collapse of small air spaces is always a potential probl em and
frequentl y occurs in disease.
Removal of Inhaled Particles
With its surface area of 50 £01 00 square met ers, the lung presents the largest sur-
face of the body to an increasingly host ile environment. Various mechanisms for
dealing wi th inhal ed part icles have been developed (see Chapt er 9). Large part i -
cles are filtered out in the nose. Sma ller particles that deposit in the conduct ing
airways are removed by a moving staircase of mucus that conti nuall y sweeps de-
hris up to the epiglott is, where it is swallowed. The mucus, secreted by mucous
gl ands and also by goblet cells in the bronchi al wall s, is propelled by mill ions of
t iny cilia, whi ch move rhythmicall y under normal condit ions but are paralyzed by
some inhaled tox ins.
The alveoli have no ci lia, and part icles that deposit there arc engulfed by large
wandering cells ca lled macrophages. The foreign material is then removed from
the lung via the lymphat ics or the blood flow. Blood. cells such as leukocytes also
participat e in the defense reaction to foreign materia l.
For each question. choose the one best answer.
1. Which of t he following statements about the blood-gas barrier of the human
lung is FALSE'
A. Much of the blood-gas barrier has a thickness of less than 0.3 I'm.
B. The total area of the blood-gas barrier exceeds 50 square met ers.
C. Most of the area of the alveolar wall is occupied by capillaries.
D. If the pressure in the capillaries rises to unphysiologically high levels.
the blood-gas barrier can be damaged.
E. Oxygen crosses the blood-gas barrier by act ive transport.
2. When oxygen moves through the thin side of the blood-gas barrier from the
alveolar gas to the hemoglobin of the red blood cell it traverses the following
layers in order:
A. Epithelial cell, surfactant. interstitium, endothelial cell. plasma, red cell
B. Surfactant, epithel ial cell. int erstiti um. endothel ial cell. plasma. red cell
Structure and Function 11
C. Surfactant . endothelial cell. interstitium. epithelial cell . plasma. red cell
D. Epithelium, interstitium, endothelial cell, plasma, red cell membrane.
E. Surfactant. epit helial cell. intersti t ium. endothelial cell . red cell
3. What is the P0
(in mm Hgl of moist inspired gas of a climber on the summit
of Mt. Everest (assume barometric pressure is 247 mm Hql ?
A. 32
B. 42
C. 52
D. 62
E. 72
4. Which of t he following st at ement s about t he airways of t he human lung is
A. The volume of t he conduct ing zone is about 150 ml.
B. The volume of the rest of the lung during resting conditions is about
2.5--3.0 lit ers.
C. A respiratory bronchiole can be distinguished from a terminal bronchiole
because the former has alveol i in its walls.
D. On the average there are about 3 branchings of the conducting airways
bef ore t he first alveoli appear in their walls.
E. In the respiratory bronchioles the predominant mode of gas flow is
diffusion rather than convection.
5. Which of t he following statements about t he blood vessels of the human
lung is FALSE?
A. The pulmonary arteries form a branching patternwhichmatches that of
the airways.
B. The average diamet er of t he capillaries is about 50 urn.
C. Most of the surface of the alveoli is covered with capillaries.
D. On t he average blood spends about 3/4 sec in the capillaries.
E. The mean pressure in t he pulmonary artery is only about 15 mm Hg at
6. Which of the following statement s about t he removal of inhaled dust in t he
lung is FALSE?
A. Very small parti cles are f ilt ered out by the nose.
B. Particles that deposit on the airways are removed by the mucus
C. The escalator is propelled by mi llions of t iny cilia.
D. The mucus comes from mucous glands and goblet cells in the
bronchial walls.
E. Particles t hat reach the alveoli are engulf ed by macrophages.
Lung Volumes
Anatomic Dead Space
How Gas Gets to the Alveoli
Physiologic Dead Space
Regional Differences in
Wenow look in moredetail at how oxygen is brought to the blood-gasbarrier by
theprocess of ventilation. First lung volumes are briefly reviewed. Then total
ventilationand alveolar ventilation, that is the amountof fresh gasgettingto the
alveoli, are discussed. The lung that doesnot participate in gas exchange is
dealt with under anatomicandphysiologic deadspace. Finallythe uneven dis-
tributionof ventilationcausedbygravityis introduced.
The next three chapters concern how inspired air gets to rhc alveoli, how gases
cross the blood-gas interface, and how they are removed from the lung by the
blood. These functions are carried out by ventilation, diffusion, and blood flow,
Figure 2-1 is a hi ghly simplified diagram of a lung. The various bronchi that
make up the conduct ing airways (Figures 1-3 and 1-4) arc now represented by a
single tube labeled anatomic dead space. This leads into the gas-exchanging re-
gion of the lung, which is bounded by the blood-gas int erface and the pulmonary
capillary blood. With each inspirat ion, about 500 ml of air enter the lung (tidal
l'Olume). Note how small a proportion of the total lung volume is represented by
Tidal volume -1-Total ven tilation
500 ml 7500 ml /mi n
-----\:-Alveolar venti lation
5250 ml /min
.;. = 1
Anatomic dead space
150 ml
Alveolar gas
3000 ml
Pulmona ry
capillary blood ' 1l /
70 ml I f
\ blood flow
\ 5000 ml / min
Figure 2-1. Diagra m of a lung showi ng ty pi cal vo lumes and fl ows. There is con-
siderable variat ion aro und these va lues .
__ ______________~ _ P a p e r
Spiromet er
Vit al
Functional +
residual Residual
capacity volume
___________t ±
Figure 2-2. Lung vo lumes. Note t hat the total lung capacity, functional resi dual
capacity. and resi dual vo lume cannot be measured wit h th e spirometer.
Ventilation 15
the anatomic dead space. Also not e the verysmall volume of capillary blood com-
pared with that of alveolar gas (compare Figure 1-7).
Lung Volumes
Before look ing at the movement of gas into the lung, a brief glance at the stat ic
volumes of the lung is hel pful. Some of these can be measured with a spirometer
(Figure 2-2). During exha lation, the bell goes up and the pen down, marking a
moving chart. First, normal breathing can beseen (tidal volume). Next the subject
tonk a maximal inspirat ion and followed this by a maximal expiration. The ex-
haled volume is called the vital capacity.. However, some gas remai ned in the lung
after a maximal expiration; thi s is the residual volume. The volume of gas in the
lung after a normal expi ration is the functional residual capacity.
Neither th e functi onal residual capacity nor the residual volume can be mea-
sured with a simple spirometer. However, a gas dilution technique can be used as
shown in Figure 2-3. The subject is connected to a spirometer containing a
known concentrat ion of hel ium, which is virtually insoluble in blood. After some
breaths, th e helium concent rat ions in the spirometer and lung become the same.
Because no helium has been lost, the amount of helium present before equi li-
bration (concentrat ion t imes volume) is:
and equals the amount after equilibration:
c, X (V, + V,)
From thi s:
.' .
...... :.
.. .
' .
, .
.' . ~ ~
. .
· .
· .
· .
· .
:' V
. ~ ~ ' . - - - ' . :
. .
Before equili brat ion After equi libration
Figure 2-3. Measurement of th e f unctional residu al capacit y by hel ium dilution.
16 Chapter 2
. 1\.
Figure 2-4. Measurement of fu nct i onal
re s idua l capaci ty (FRC) wi t h a bod y
plethysmograph. When the subject makes
an inspi rat ory effort agai nst a closed air -
way, he sli ghtly i ncreases th e vo lume of hi s
l ung, air way pressur e decreases, and box
pres sure increases. From Boyl e' s law, l ung
vo lume is obtained (see t ext ).
" .
, ,
In practi ce, oxygen is added to the spirometer during equilibrati on to make up
for that consumed by the subject, and also carbon dioxide is absorbed.
Ano the r way of measuring t he functi onal residual capacity (FRC) is with a
bod y plethysmograph (Figure 2-4) . This is a large ai rti ght box, like an old tel e-
phone booth, in wh ich the subject sits. At the end of a normal expirati on, a
shutt er closes the mouthpiece and the subject is asked to make respir atory
efforts. As th e subject tries to inha le. he (or she) expands the gas in his lungs,
and lung volume increases, and the box pressure rises beca use its gas volume
decrea ses. Boyle' s law states that pressure X volume is constant (at constant
Therefor e, if the pressures in the box before and after the inspiratory effort are
PI and Pz, respecti vel y, VI is the pre -Insplracorv box volume and t1V is the
cha nge in volume of the box (or lung), we can write:
PI VI = P, (VI - Ll. V)
Thus Ll. V can be obta ined.
Next, Boyle's Law is applied to the gas in the lung. Now:
P, V
= P
+ Ll. V)
where p} and P4 are the mouth pressures before and after the inspiratory effort.
and V
is the FRC. Thus FRC can be obtained.
The body plethysmograph measures the total volume of gas in the lung,
incl uding any that is trapped behi nd cl osed airways (an exa mple is shown in
Figure 7 ~ 9 ) and that therefore does not communicate with the mouth. Bycon-
tr ast, the helium dilut ion method measures only communicating gas, or vent i-
lated lung volume. In young normal subjects, these volumes are virtually the
same, but in pat ients with lung disease, the venti lated vol ume may be con-
siderably less than the tot al volume because of gas t rapped behind obst ruct ed
17 Ventilation
ze up
rs the
Lung Volumes
• Tidal volume and vital capacity can be measured with a simple spirometer
• Total lung capacity, functiona l residual capacity and residual volume need an
additional measurement by helium dilution or the body plet hysmograph
• Helium is used because of its very low solubi lity in blood
• The body plethysmograph depends on Boyle's Law PV=K at constant
Suppose the volume exhaled with each breat h is 500 ml (Figure 2- \) and there
are 15 breat hs/min . Then the total volume leaving the lung each minute is 500
X 15 = 7500 ml/min. This is known as the total ventilation. The volume of air en -
tering the lung is very slightl y greater because more oxygen is taken in than car -
bon dioxide is given out.
However, not all the air that passes the lips reaches the alveolar gas compart-
ment where gas exchange occurs. Of each 500 ml inhal ed in Figure 2-1, 150 ml
remain behind in the anatomic dead space. Thus, th e volume of fresh gas enter-
ing the respiratory zone each minute is (500 - 150) X 15 or 5250 ml/min. This
is called th e alveolar ventilation and is of key importance because it represent s the
amount of fresh inspired air available for gas exchange (strictly, the alveolar ven-
tilation is also measured on expirat ion, but the volume is almost the same.)
The total ventilat ion can be measured easily by having the subject breathe
through a valve box that separates the inspired from the expired gas, and collect-
ing all th e expired gas in a bag. The alveolar venti lation is more difficult to de,
rermine. One way is to measure the volume of the anatomic dead space (see be-
low) and calculate the dead space vent ilation (volume X respiratory frequency).
This is then subtracted from the total vent ilat ion.
We can summarize thi s convenientl y with symbols (Figure 2 ~ 5 ) . Using V to
denot e volume, and the subscripts T, D, and A to denote t idal, dead space, and
alveolar, respecti vely:
where n is the respiratory frequency.
effort ,
VT = V" + VA*
. n = Vi) . n + VA · n
where Vmeans volume per unit ti me, V
is expired total ventilat ion, and V
\ 1A are the dead space and alveolar vent ilat ions, respecti vely (see Appendix A for
a summary of symbols).
*Nore that VAhere means the volume of alveolar gas in the tidal volume, not the total
volume of alveolar gas in the lung.
- V
A difficulty with this method is that the anatomic dead space is not easy to mea-
sure, alt hough a value for it can be assumed with littl e error. Note that alveolar
vent ilation can be increased by raising either tidal volume or respirator y fre-
quency (or both). Incr easing tidal volume is often more effecti ve because th is rei
duces the proport ion of each breath occupied by the anatomic dead space.
Another way of measuring alveolar vent ilation in normal subjects is from the
concentrat ion of CO
in expired gas (Figure 2; 5). Because no gas exchange oc-
cur s in the ana tomic dead space, there is no CO
there at the end of inspirat ion
(we can neglect the small amount of CO
in the air.] Thus, because all the ex-
pired CO
comes from the alveolar gas,
% CO,
wher e \1<:0 2 means the volume of CO
exha led per uni t t ime.
. V
, X too
VA= - - - ' : ~ : : : : - -
. % CO,
The % CO,jl OO is often called the fract ional concentrat ion and is denot ed by
Thus, the alveolar vent ilation can be obtained bydividing the COl output
by the alveolar fract ional concentrat ion of thi s gas.
Note that the partial pressure of CO, (denot ed Pco, ) is proport ional to the
fract ional concentrat ion of the gas in th e alveoli, or P
= F
X K wher e K
is a constant.
Figure 2-5. The t idal volume (V
) is
a mi xt ur e of gas f rom t he
anato mic dead space (Vol and a
cont ri but ion f rom the alveolar gas
(VA)' The concent rat ions of CO
are shown by t he dots. F, f ract ional
concent r at ion; I, i nspired; E, ex-
pi red. Compare Figu re 1-4.
Ventilation 19
Because in normal subjects the Pet)1 of alveolar gas and arterial blood are virtu-
ally ident ical, the arterial r eX); can he used rodetermine alveolar vent ilation. The
relati on between alveolar vent ilation and P
o z
is of cruci al importance. If the
alveolar ventilati on is halved (and COl production remains unchanged), for e x ~
ampl e, the alveolar and arter ial pet)zwill double.
Anatomic Dead Space
This is the volume of the conduct ing airways (Figures 1-3 and 1-4), The normal
value is about 150 rnl, and it increases with large inspirations because of the trac-
tion or pull exerted on the bronchi by the surrounding lung parenchyma. The
dead space also depends on the size and posture of the subject.
The volume of the anatomic dead space can be measured by Fowler' s method.
The subject breat hes through a valve box. and the sampling tube of a rapid n i-
twgen analyzer cont inuously samples gas at the lips (Figure 2 ~ 6 A ) . Following a
single inspirat ion of 100%O
, the N
concentration rises as the dead space gas is
increasingly washed out by alveolar gas. Finally, an almost un iform gas concen-
tration is seen represent ing pure alveolar gas. This phase is often called the al ve-
olar "plateau," although in normal subjects it is not quite flat, and in pat ients with
lung disease it may rise steeply. Expired volume is also recorded.
The dead space is found by plott ing N
concentration against expired volume
and drawing a vert ical line such that area A is equal to area Bin Figure 2F6B.The
dead space is the volume expired up to the vert ical line. In effect , this method
measures the volume of the conducti ng airwaysdown to the midpoint of th e tran-
sit ion from dead space to alveolar gas.
Physiologic Dead Space
Another way of measuring dead space is Bohr's method, Figure 2-5 shows that all
the expired CO
comes from the alveolar gas and none from the dead space.
Therefore, we can write
subst itut ing
= VA+ V
- VI)
' FE= (V
- V
) , FA
whence =
We saw earlier tha t the part ial pressure of a gas is proporti onal to its concentru-
t ion. Thus,
PAco ,
(Bohr equat ion)
20 Chapter 2
A Start of
inspi ratio n
End of
expi ration
. ~
C 40
0 Alveolar
Start of
plat eau
expirati on
ltli ~
' 'If' '
0 5 10
Time (sec)

0 0.4 0.6 0.8
Expired volume (liters)
Figure 2-6. Fowler's met hod of measuri ng t he anato mic dead space wit h a rapi d
an alyzer. A shows that f ollowing a t est insp irat io n of 100% O
, t he N
tration rises during expiration to an almost level " plateau" representing pure
alveolar gas. In B, N
concent rat ion is plott ed agai nst expi red volume, and t he
dead space is t he volume up to the vertical dashed li ne, whi ch makes th e areas A
and B equal.
where A and E refer to alveolar and mixed expired. respect ively (see Appendix
A). The normal rat io of dead space to tidal volume is in the range 0. 2 to 0.35 dur-
ing rest ing breathing. In normal subj ects, the PCD 2 in alveolar gas and that in ar-
teria l blood are virt ually ident ical so th at the equat ion is therefore often written
VD Pacoz - PEe"'oz
VT Paco,
i 'v entilation
• Total vent ilation is t idal volume x respiratory frequency
• Alveolar ventilation is the amount of fresh gas getting to the alveoli, or
IV, - Vol X n
• Anatomic dead space is t he volume of the conducting airwavs, about 150 ml
• Physiologic dead space is t he volume of gas that does not eliminate CO
• The two dead spaces are almost the same in normal subjects, but the
physiologic dead space is increased in many lung diseases
It should he not ed that Fowler's and Bohr 's methods measure somewhat different
th ings. Fowler's met hod measures the volume of the conducting airways down to
the level where the rapid dilution of inspired gas occurs with gas already in the lung.
This volume is determined by the geometry of the rapidly expanding airways (Fig;
ure 1-5), and because it reflects the morphologyof the lung, it is called the anatomic
dead space. Bohr's method measutes the volume of the lung that does not el iminate
, Because this is a funct ional measurement , the volume is called the physiologic
dead space. In normal subjects, the volumes are very nearly the same. However, in
pat ients with lung disease, the physiologic dead space may be considerably larger
because of inequalityof blood flowand vent ilation within the lung (see Chapter 5).
Regional Differences of Ventilation
So far we have been assuming that all regions of the normal lung have the same
vent ilat ion. However, it has been shown that the lower regions of th e lung
vent ilate bett er than do the upper zones. This can he demonstrated if a subject
inhales radioact ive xenon gas (Figure 2; 7) . When the xenon-133 enters the
~ ~ ~
" "0
,2 40
w 20
Lower Middle Upper
zone zone zone
Figure 2-7. Measurement of regio nal differences i n vent i lat ion wit h radi oacti ve
xenon. When t he gas is i nhaled, it s radiation can be detected by cou nters outsi de
the chest . Note that t he vent ilat ion decreases f rom t he lower to upper regi ons of
t he upr ight lung.
counting field, its radiati on penetrates the chest wall and can be recorded by a
bank of count ers or a radiation camera. In this way, the volume of the inhaled
xenon going to various regions can be determined.
Figure 2-7 shows the results obtai ned in a series of normal volunteers using th is
method. It can be seen that ventilation per unit volume is greatest near t he bot-
tom of the lung and becomes progressively small er toward the top. Other mea-
surements show that whe n the subject is in the supine posit ion, th is difference
disappears with the result that apical and basal ventilat ions become the same.
However, in that posture, the ventilat ion of the lowermost (posterior ) lung ex-
ceeds that of the uppermost (anterior) lung. Again in the lateral positi on (subject
on his side) the dependent lung is best venti lated. The cause of these regional dif-
ferences in vent ilati on will be dealt with in Chapter 7.
For each question, choose t he one best answe r.
1. All of the following can be measured with a simple spirometer and stop-
watch EXCEPT:
A. Tidal volume.
B. Functional residual capacity.
C. Vital capacity.
D. Total ventilation.
E. Respiratory f requency.
2. All of the f ollowing statements about the pulmonary acinus are true
A. All the oxygen uptake occurs in the acini.
B. Percentage change in vol ume of t he acini during inspiration exceeds
t hat of the whol e lung.
C. Volume of the acini is greater than 90% of t he total volume of the lung
at FRC.
D. Each acinus is supplied by a terminal bronchiole.
E. Aci ni at the base of the upright human lung at FRC are larger than those
at the apex.
3. In a measur ement of FRC by helium-dilution, the original and final helium
concentrations were 10 and 6%, and the spirometer volume was kept at 5
lit ers. What was the vol ume of the FRCin liters?
A. 2.5
B. 3.0
C. 3.3
D. 38
E. 5.0
4. A patient sits in a body plet hysmograph (body box) and makes an expirat ory
effort against his closed glottis. What happens to the followi ng: pressure in
the lung airways. lung volume. box pressure. box volume?
Ai rway Lung Box Box
Pressure Volume Pressure Volume
A. l r r l
B. l t l r
c. r l i l
D. i l l r
E. r il l
5. If CO2 production remains constant and alveolar ventilation is increased
three-fold, the alveolar Pee- afte r a steady state is reached will be what per·
centage of its former value?
A. 25
B. 33
C. 50
D. 100
E. 300
6. In a meas urement of physiologic dead space using Bohr's method the alveo-
lar and mixed expired Pco, were 40 and 30 mm Hg. respectively. What was
the ratio of dead space to tidal volume?
A. 0.20
B. 0.25
C. 0.30
D. 0 35
How Gas Gets Across the Blood-Gas Barrier
of Diffusion
ion and Perfusion
it at ions
gen Uptake Along the
, monary Capillary
easurernent of Diffusing
Capacit y
Reaction Rate s with
Interpretation of Diffusing
Capacity for CO
Transfer Across the
Pulmonary Capillary
=- now consider howgasesmoveacross the blood-gasbarrier bydiffusion.
="57 the basic laws of diffusionare introduced. Next we distinguish between
z andperfusion-limitedgases. Oxygenuptakealongthe pulmonary
-=z ary is then analyzed, and there is asection on themeasurementof
_ capacity using carbonmonoxide. The finite reactionrate of oxygen
-- ,emog/obin is convenientlyconsidered with diffusion. Finally there is a
_ reference to theinterpretation of measurements of diffusing capacity, and
_iss ble limitations of carbon dioxidediffusion.
chapter, we looked at how gas is moved from the atmosphere to the
r in the reverse direction. We now come to the tr ansfer of gas across the
'"= barrier. This process occurs bydiffusion. Only 60 years ago, some phys-
-- .. beli eved that the lung secreted oxygen into the capillaries, that is, the
. A
Vgas OC T · 0 · (P,- P2)
....tl Thickness
Figure 3-1. Diff usion t hrough a t issue sheet . The amount of gas t ransfer red is pro-
po rt io nal to the area (AI, a diffusi on const ant (0) , and th e di ff er ence i n partial pres-
sure (P,- P2), and is i nver sel y proporti onal t o the t hickness (T). The constant is
proport ional t o the gas solu bility (Sol) but i nversely pr oportiona l to t he squ are
root of it s mo lecular weight (MW).
oxygen was moved from a region of lower to one of higher part ial pressure . Such
a process was thought to occur in the swim bladder of fish, and it requires energy.
But more accurate measurements showed that thi s does not occur in the lung and
that all gases move across the alveolar wall bypassive diffusion.
Laws of Diffusion
Diffusion through tissues is described by Fick' s law (Figure 3-1). This states that
the rate of transfer of a gas through a sheet of t issue is proportional to the ti ssue
area and th e difference in gas partial pressure between th e two sides, and inversely
proportional to the tissue thickness. As we have seen, the area of the blood-gas
bar rier in th e lung is enormous (50 to 100 square meters), and the th ickness is
only 0.3 urn in many places (Figure 1 ~ 1) , so the dimensions of the harrier are ideal
for diffusion. In addit ion, the rat e of transfer is proport ional to a diffusion con-
stant wh ich depends on the properti es of the t issue and the particular gas. The
constant is proportional to the solubility of the gas and inversely proporti onal to
the squate toot of the molecular weight (Pigure 3- 1). This means tha t CO, dif-
fuses abou t 20 ti mes more rapidly than does Oz through tissue sheets because it
has a much h igher solubility but not a very different mol ecular weight.
Fick's Law of Diffusion
• Rate of diff usion of a gas through a t issue slice is proportional to the area
but inversely proportional to t he t hickness
• Diff usion rate is proportional to the partial pressure difference
• Diff usion rate is proport ional to the solubility of the gas in the tissue but
inversely proport ional to t he square root of t he molecular weight
Diffusi on
Diffusion and Perfusion Limitations
- ppose a red blood cell enters a pulmonary capillary of an alveolus which con-
cains a foreign gas such as carbon monoxide or ni trous oxide. How rapidl y will the
part ial pressure in the blood rise? Figure 3-2 shows the t ime courses as the red
clood cell moves th rough the capillary, a process that takes about 3/4 sec. Look
first at carbon monoxide. \Vhen t he red cell enters the capillary, carbon monox-
IJ e moves rapidlyacross the extremely thin blood-gas barrier from the alveolar gas
int o the cell. As a result , the content of carbon monoxide in the cell rises. How;
ever. because of the t ight bond that forms bet ween car bon monoxide and
hemoglobin within the cell, a large amount of carbon monoxide can be taken up
bv the cell wit h almost no increase in part ial pressure. Thus, as the cell moves
through rhe capillary, the carbon monoxide part ial pressure in the blood hardly
changes, so that no appreciable back pressure devel ops, and the gas conti nues to
move rapidly across the alveolar wall. It is clear, therefore. that the amount of car;
bon monoxide th at gets into the blood is limited bythe diffusion propert ies of the
Hood-gas barrier and not by the amount of blood available' The transfer of cat-
ton monoxide is therefore said to be diffusion limited.
Cont rast the time course of nitrous oxide. When thi s gas moves across the
alveolar wall into the blood, no combination with hemoglobin takes place. As €I
result, the bloo..i has nothi ng like the avidity for nitrous oxide that it has for car;
ron monoxide, and the part ial pressure rises rapidly. Indeed, Figure 3-2 shows
tha t the part ial pressure of ni trous oxide in the blood has virt ually reached that of
the alveolar gas by the time the red cell is only one-tent h of the way along the
capillary. After this point , almost no ni trous oxide is transferred. Thus, the
amount of th is gas take n up bythe hlood depends ent irely on the amount of avail;
able blood flow and not at all on th e diffusion propert ies of the blood-gas barrier.
The transfer of nitrous oxide is therefore perfusion limited.
What of Oz? Its time cour se lies between those of carbon monoxide and ni -
trous oxide. Oz combines with hemoglobin (unlike nit rous oxide) but with noth-
ing like the avidity of carbon monoxide. In other words, th e rise in partial pres;
sure when Or enters a red blood cell is much greater than is the case for the same
number of molecules of carbon monoxide. Figure 3-2 shows that the Po, of th e
red blood cell as it enters the capillary is already about four-tenths of the alveolar
value because of the Oz in mixed venous blood. Under typical resting condit ions,
the capill ary Po, virtuall y teaches th at of alveolar gas when the ted cell is about
one-third of the way along the capillary. Under these conditions, O
transfer is
perfusion limi ted like ni trous oxide. However, in some abnor mal circumstances
when the diffusion propert ies of the lung are impai red, for example, because of
th ickening of the blood-gas barrier, the blood Po, does not reach the alveolar
value by the end of the capillary, and now there is some diffusion limitat ion as
*Th is introductorydescript ion of carbon monoxide transfer is not completely accurate be-
cause of the rate of react ion of carbon monoxide with hemoglobin (sec later).
Start of
Alveolar ---+
End of
o .25 .50 .75
Time in capillary (sec)
Figur e 3· 2. Upta ke of car bon monoxi de, nit rous oxi de, and O
along t he pul -
monary capill ary. Note t hat t he bl ood partial pressur e of nitrous oxide vi rt uall y
reaches t hat of alveol ar gas very early in t he capil lary so t hat t he transf er of th is
gas is perfusio n limited. By cont rast , t he part ial pressure of carbo n monoxi de in
the blood is almost unchanged so that its t ransfer is di ff usion limited. O
tr ansfer
can be perf usion limit ed or partl y diffusion li mit ed, depending on the conditi ons.
A more detailed analysis shows that whether a gas is diffusion limited or not
depends essent ially on its solubility in the blood-gas barrier compared with its
"solubility" in blood (actually the slope of th e dissociation curve; see Chapter 6) .
For a gas like carbon monoxide, these are very differen t, whereas for a gas like ni-
trous oxide, they arc the same. An analogy is the rate at which sheep can enter a
field through a gate. If the gate is narrowbut the field is large, the number of sheep
that can en ter in a given time is limited by the size of the gate. However, if bot h
the gate and the field are small (or both are big) the number of shee p is limit ed
by the size of the field.
Oxygen Uptake Along the Pulmonary Capillary
Let us take a closer look at the uptake of O
by blood as it moves through a pul-
monary capillary. Figure 3-3A shows that th e P
in a red blood cell entering the
capillary is normally about 40 mm Hg. Across the blood-gas barrier, only 0.3 urn
away, is the alveolar P Ol of 100 mm Hg. Oxygen floods down this large pressure
gradient, and the Poz in the red cell rapidly rises: indeed, as we have seen, it very
nearl y reaches the Po, of alveolar gas by the time the red cell is only one-third of
Diffusion 29
- .. way along the capillary. Thus, under nonnal circumstances, the difference in
:-""\.. between alveolar gas and end-capillary blood is immeasurably small-a mere
rraction of a mm Hg. In other words, the diffusion reserves of the normal lung are
~ rrnous.
\J;;rith severe exercise, the pulmonary blood flow is greatly increased, and the
urne normallyspent by the red cell in rhe capillary, about 3/4 sec, may be reduced
· 0 as little as one-third of thi s. Therefore, the time available for oxygenat ion is
~ 5 , but in normal subjects breathing air there is generally st ill no measurable fall
m end-capillary Par However, if the blood-gas barrier is markedly thickened
cv disease so that oxygen diffusion is impeded, the rat e of rise of P02 in th e red
Nood cells is correspondingly slow, and the POl may not reach that of alveolar gas
~ 50
Grossly abnormal
.75 .50 .25
o"-__-L -'-_ _ ---J
50 - - - - -- -- - - - - --.:;; -... - _ - - - - -
t Grossly abnormal
.75 .50 .25
OL- -'- --'- --'
Time in capillary (sec)
Figure 3-3. Oxygen t ime courses i n t he pulmonary capi llary when diff usion is nor-
mal and abno rma l (f or example. becau se ofthicke ni ng of t he blood-gas barri er by
di sease). A shows ti me courses when the alveolar P02is normal. B shows slowe r
oxy genat ion when the alveo lar P02 is abnormall y low. Not e t hat in both cases, se-
vere exerci se reduces t he t ime available for oxy genat io n.
before the ti me available for oxygena tion in the capillary has run out . In thi s case,
a measurable difference bet ween alveolar gas and end-capil lary blood for P 0 2
may occur.
Another way of stressing th e diffusion properties of the lung is to lower t he
alveolar Pa z (Figure 3-3B). Suppose th at thi s has been reduced to 50 mm Hg,
by the subject either going to hi gh alt itude or inhal ing a low O
mixture. Now,
although the Po , in the red cell at the starr of the cap illar y may only he about
20 mm Hg, the partial pressure difference responsible for driving the O
the blood-gas harriet has been reduced from 60 rnrn Hg (Figure 3-3A) to only
30 mm Hg, O
therefore moves across more slowly. In addit ion, the rat e of rise
of Po , for a given increase in O
concentra t ion in the blood is less than it was
becau-se of th e steep slope of the O
dissoci at ion curve whe n the P 0 2 is low (see
Chapt er 6) . For bot h of these reasons, therefore, the rise in Po , along the cap-
illary is relati vely slow, and failure to reach the alveolar P0 2- is more likely.
Thus, severe exercise at very high al titude is one of the few sit uat ions where di f-
fusion impairment of O
transfer in normal subjects ca n be convinci ngly
demonstrated. By the same token, patients with a thi ckened blood- gas barrier
will be most likel y to show evidence of diffusion impairment if they breathe a
low oxygen mixt ure, especially if they exercise as well .
Diffusion of Oxygen Acros s the Blood-Gas Barrier
• At rest the P0
of the blood virt ually reaches that of t he alveolar gas after
1/3 of its ti me in the capillary
• Blood spends only 3/4 sec in the capillary at rest
• On exercise the time is reduced to perhaps 1/4 sec
• The diffusion process is challenged by exercise, alveolar hypoxia, and
thickening of the blood-gas barrier
Measurement of Diffusing Capacity
We have seen th at oxygen transfer into the pulmonary capillary is normally lim-
ited by the amount of blood flow available, although under some ci rcumstances
diffusion limi tat ion also occurs (Figure 3 ~ 2 ) . By cont rast, th e transfer of carbon
mon oxide is limi ted solely by diffusion, and it is there fore the gas of choice for
measuring the diffusion properti es of the lung. At one time O
was employed un-
der hypoxic condit ions (Figure 3 ~ 3 B ) , but this technique is no longer used.
The laws of diffusion (figure 3 ~ 1) state that the amount of gas transferred
across a sheet of tissue is proport ional to the area, a diffusion constant, and the
difference in partia l pressure, and inversely proport ional to t he thickness, or
. A
Vgas = - . D· (P, - P, )
Now for a complex structure like the blood-gas barrier of the lung, it is nor possible
to measure the area and thickness duri ng life. Instead, the equati on is rewritten
Vgas = D
· (P, - P, )
_ ur ement of Diffusing Cap acity
: ::-on monoxide is used because the uptake ot t his gas is diffu sion-limited
t'T'a' diffu sing capacity is about 25 ml.min r l.mrn Hg-
: .; ..IS ng capacity increases on exercise
_ L. is called the diffusinl; capacit)'of thelungand includes the area, thickness,
_ - sion propert ies of the sheet and the gas concerned. Thus, the diffusing
.... lo r carbon monoxide is given by
OL = PI - P,
P and P2arc the partial pressures of alveolar gas and capillary blood, rcspec-
Bu as we have seen (Figure 3 ~ 2 ) , the part ial pressure of carbon monoxide in
rv blood is extremelysmall and can generally he neglected. Thus,
= - -
. Peco
rds. the diffusing capacity of the lung for carbon monoxide is the volume
n monoxide transferred in milliliters per minute per mm Hg of alveolar
r rC::':' Ufe .
-.. frequenrlv used rest is the singlebreach method, in which a single inspiration
me mixture of carbon monoxide is made and the rate of disappearance of
"'11 monoxide from the alveolar gas dur ing a IOvscc brcathhold is calculated,
.. usually done by measuring the inspired and expired conce ntrat ions of car-
noxide with an infrared analyzer. The alveolar concentration of carbon
xide is not constant during the breathholding period, but allowance can be
: r thar. Helium is also added to the inspired gas to give a measurement of
lurne by dilution.
e normal value of the diffusing capacity for carbon monoxide at rest is
- : - ml : min- 1 . mm Hg-
, and it increases to two or three times this value
.. ercise because of recruitment and dist ension of pulmonary capillaries (sec
«er 4).
Reaction Rates With Hemoglobin
we have assumed that all the resistance to the movement of O
and CO rc-
he barrier bet ween blood and gas. However, Figure 1-1 shows that the
ncrh from the alveolar wall to the center of a red bl<:XXI cell exceeds that
'all itself, so that some of the diffusion resistance is locat ed withi n the c a p ~
in addit ion, there is another type of resistance to gas transfer that is most
iently discussed with diffusion, that is, the resistance caused by the finit e
: react ion of O
or CO wit h hemoglobin inside the red blood cell.
ben 02: (or CO) is added to blood, its combina t ion with he moglobin is quite
-eina well on the way to complet ion in 0. 2 sec. However, oxygenat ion
~ ~ J
occurs so rapidly in the pulmonary capillary (Figure 3-3) that even thi s rapid re-
act ion significantly delays the loading of 0 , by the red cell. Thus, the uptake of
0 , (or CO) can be regarded as occurring in two stages: (1) diffusion of 0 , through
the blood-gas barrier (includi ng the plasma and red celt interior); and (2) reac-
t ion of the O
with hemoglobin (Figure 3 ~ 4 ) . In fact, it is possible to sum the two
resul tan t resistances to produce an overall "diffusion" resistance.
We sawthat the diffusingcapacit y of the lung is defined as D
= Vgas!(P
- P,) ,
that is, as the flowof gas di vided by a pressure difference. Thus, the inverse of D
is pr essur e difference divi ded by flow and is therefore anal ogous to electrical re-
sistance. Consequently, the resistance of the blood-gas barr ier in Figure 3A is
shown as l/D
wher e M means membrane. Now the rate of reaction of O
CO) with hemoglobin can be described by 8, wh ich gives the [ate in ml per
minute 0£02 (or CO) which combine wit h 1 ml of blood per mm lIg partial pres-
sure of 0 , (or CO). This is analogous to the "diffusing capacity" of 1 mlof blood
and, whe n multiplied by the volume of capillary blood (VJ, gives the effective
"diffusing capacity" of the rate of reacti on of O
with hemoglobin. Again its in-
verse, 1/ (8' VJ, describes the resistance of this react ion. We can add the resis-
tances offered by the membrane and the blood to obtain the total diffusion rcsis-
ranee. Thus, the complete equation is
In practi ce, the resistances offered by the membrane and blood components are
approximately equal, so that a reduction of capillary blood volume by disease can .
reduce the diffusing capacity of the lung. efor co is reduced if a subject breathes
a high 0, mixture , because the 0, competes with the CO for hemoglobin. As a
result , the measured diffusing capacity is reduced by O
breathing. In fact, it is
possible to separately determine OMand Vc by measuring the diffusing capaci ty
for CO at different Po, values.
Figure 3-4. The diffusi ng capacity of th e lung (Dd is made up of two component s,
th at due to t he diffusi on process itsel f and th at attri but abl e to t he ti me take n for
(or CO) t o react wit h hemoglobin.
ion Rates of O
and CO with Hemoglobin
<eection rate of O
is fast but because so little time is available in the capil-
srv. thi s rate can become a limit ing factor
- e resistance to the uptake of O
att ributable to reacti on rate is probably
ut the same as that due to diff usion across the blood-gas barrier
- "'e reaction rate of CO can be altered by changing the alveolar POz. In this
'ay the separate contri butions of the diffusion properti es of the blood-gas
carr er and the volume of capillary blood can be derived.
Int erpret at ion of Diffusing Capacity for CO
dear that the measured diffusing capacity of the lung for CO depends not
on the area and thickness of the blood-gas barrier but also on the volume of
.J in the pulmonary capillaries. Furthermore, in the diseased lung, the mea-
cement is affected by the distri but ion of diffusion propert ies, alveolar volume,
cap illary blood. For these reasons, the rerm transfer factor is somet imes used
- racularlv in Europe) to emphasize that the measurement does not solely re-
cr the diffusion propert ies of t he lung.
Transfer Across the Pulmonary Capillary
have seen that diffusion of COz through tissue is about 20 times faster than
0 ; 0, because of the much higher solubility of CO
(Figure 3-1). At first
' . the refore, it seems unlikely tha t CO
elimination could be affected by dif-
'Il di fficult ies, and indeed thi s has been the general belief. However, the rc-
- '" 01CO, with blood is complex (sec Chapter 6) , and although there is some
certainty about the rates of the various react ions, it is possible that a difference
n end-capillary blood and alveolar gas can develop if the blood-gas barrier
-::::: quest ion, choose the one bes t answer.
_sOng Fick's law of diff usion of gases t hrough a t issue slice, if gas X is 4
- ..... as as soluble and 4 ti mes as dense as gas Y, what is t he ratio of the
: ":": usion rates of Y to X?
_. 0.5
J . 4
_ 8
- "" exercising subject breathes a low concent rati on of CO in a steady state.
:. t:18 alveolar Pco, is 0.5 mm Hg and t he CO upta ke is 30 ml.min1, w hat is
tr e diff using capacity of t he lung for CO in ml .mmr l .mrn Hg- ' ?
_ _ _ ~ _ 30
C. 40
D. 50
E. 60
3. In a normal person, doubling the diffus ing capacity of the lung would be
expected to:
A. Decrease arterial Peo2 during resting breathing.
B. Increase resting oxygen uptake when the subject breathes 10% oxygen.
C. Increase the uptake of nitrous oxide during anesthesia.
D. Increase the arterial P0
during resting breathing.
E. Increase maximal oxygen uptake at extreme altitude.
4. A subject inhales several breaths of a gas mixture containing low
concentrations of carbon monoxide and nitrous oxide. Which of the
following statements is FALSE?
A. The partial pressures of carbonmonoxide in alveolar gasandend-
capillary blood wi ll be virt ually the same.
B. The partial pressures of nitrous oxide in alveolar gas and end-capillary
blood wi ll be virtually the same.
C. Carbon monoxide is transferred into the blood along the whole length of
t he capillary.
D. Almost all of the nitrous oxide will be taken up in the early part of the
E. The uptake of carbon monoxide can be used to measure the diff using
capacity of the lung.
5. All of the following statements about the diffusing capacity of the lung are
t rue J:XCEPT:
A. It isbest measured with carbon monoxide because this gas diffuses
very slowly across the blood-gas barrier.
B. Diffusion-limitation of oxygen transfer during exercise is more likely to
occur at high altitude than sea level.
C. Breathing oxygen reduces t he measured diffusing capacity for carbon
monoxide compared with air breathing.
D. It is decreased by removal of one lung.
E. It is decreased in pulmonary fibrosis whi ch t hickens t he blood-gas
6. All of the following would be expected to reduce the diffusing capacity of
the lung for carbon monoxide EXCEPT:
A. Emphysema which causes loss of pulmonary capillaries.
B. Asbestosis which causes thickeni ng of the blood-gas barrier.
C. Pulmonary embolism which cuts of f the blood supply to part of the lung.
D. Exercise in a normal subject .
E. Severe anemia.
Active Control of the
Water Balance in the lung
Other Functions of the
Pulmonary Circulation
Metabolic Functions of
the lung
~ Q O Q
Blood Flow and Metabolism
How the Pulmonary Circulation Removes Gas From
the Lung and Alters Some Metabolites
Pressures Within Pulmonary
Blood Vessels
Pressures Around Pulmonary
Blood Vessels
Pulmonary Vascular Resistance
Measurement of Pulmonary
Blood Flow
Distribution of Blood Flow
We nowturn tohowthe respiratory gases areremovedtrotn the lung. First the
pressuresinside andoutsidethe pulmonary bloodvessels are considered, and
then pulmonary vascular resistence is introduced. Next we look at the measure-
ment 01 totalpulmonary blood flow andits unevendistribution caused bygrav-
ity. Activecontrol 01 the circulation is then addressed10110wed by fluid balance
in the lung. Finally othertunctions 01the pulmonary circulation aredealt with,
particularly the metabolic lunctions 01the lung.
The pulmonary circulat ion begins at the main pulmonary artery, which receives
me mixed venous blood pumped by the right ventricle. This artery then branches
successively like the system of airways (Figure 1-3), and, indeed, the pulmonary
eries accompany the airways as far as the terminal bronchi oles. Beyond tha t ,
the y break up to supply the capillary bed which lies in th e walls of the alveoli
(Figures 1-6 and 1-7). The pulmonary capillaries form a dense net work in the
alveolar wall which makes an exceedingly efficient arrangement for gas exchange
(Figures I - I , 1-6, and 1-7). So rich is the mesh that some physiologists feel that
it is misleading to talk of a network of individual capillary segments and prefer to
regard the capillary bed as a sheet of flowing blood interrupted in places by posts
(Figure 1-6), rather like an underground parking garage. The oxygenated blood is
then collected from the capillary bed by the small pulmonary veins that run he-
tween the lobules and eventually uni te to form the four large veins (in humans),
whic h drai n into the left atrium.
At first sight, this circulation appears to be simply a small version of the svs-
(ernie circulat ion which begins at the aorta and ends in the right atrium. How-
ever, there are import ant differences between the two ci rculati ons, and confusion
frequently results from attempt s to emphasize similarities between them.
Pressures Within Pulmonary Blood Vessels
The pressures in the pulmonary circulation are remarkably low. The mean pres-
sure in the main pulmonary art ery is only about 15 mm Hg; the systolic and dtas-
rol ic pressures are about 25 and 8 mm Hg, respectively (Figure 1). The pressure
is th erefore very pulsat ile. By contrast , the mean pressure in the aort a is about 100
mm Hg- about six times more than in the pulmonary art ery. The pressures in th e
right and left atr iums arc not very dissimilar-about 2 and 5 mm Hg, respect ively.
Thus, the pressure di fferences from inlet to outlet of the pulmonary and systemic
systems are about (15 - 5) = 10 and (100 - 2) = 98 mm Hg, respect ively-a
factor of 10.
In keeping with these low pressures, the walls of the pulmonary. artery and its
branches are remarkably thi n and conta in relat ively smooth muscle (t hey
Mean = 100
Pulmonary Systemic
Cap 20
2 5
Vein Vein
Figure 4-1. Compa rison of pressur es (mm Hg) in t he pulmonary and syst emic ci r-
culat ions. Hydrost atic di ff erences modi fy t hese.
e easily mistaken for veins). Thi s is in striking contrast to the systemic circula-
n where the arteries generally have th ick walls and the arterioles in part icular
ve abundant smooth muscle. ---_.
for these difference s become clear when the funct ions of the t wo
circulat ions are compared. The systemic circulat ion regulates the supply of blood
[ various organs, including t hose which may be far above the level of the heart
he upstretched arm, for example) . Bycontrast, the lung is required to accept the
whole of the cardiac out put at all times. It is rarely concerned with directi ng
blood from one region to another (an excepti on is local ized alveolar hypoxia, see
below), and its arterial pressure is therefore as low as is cOllsistent with lifting
blood to the top of the lung. This keeps the worKoFilleright he art as small as is
feasible for efficient gas exchange to occur ---- -
The pressure within [he pulmonary capillaries is uncerta in. The best evidenc e
suggests that it lies about halfway between pulmonary arterial and venous pres-
sure, and probably tha t much of the pressure drop occurs within the capillary bed
itself. Certainly the distribut ion of pressures along the pulmonary circulation is
tar more symmetrical than in its systemic counterpart , where most of the pressure
drop is just upstream of the capillaries (Figure 4-1) . In addit ion, the pressure
within the capillaries varies consjderablv throughout t he lung. because
below) . ,.,
Pressures Around Pulmonary Blood Vessels
The pulmonary capillaries arc unique in that they arc virtually surrounded by gas
( Figures I- I and 1-7). It is true that th ere is a very thin layer of epithelial cells lin-
ing the alveoli, but the capillaries receive lit tle support from this and, co nse-
quently, arc liable to collapse or distend, depending on the pressures within and
around them. The latter is very close to alveolar pressure. (The pressure in the
alveoli is usuallvclosero atmospheric pressure: indeed, during breathholding with
the glottis open, the two pressures are identical.) Under some spec ial conditions,
the effect ive pressure around the capillaries is bythe surface tension of
the fluid liningthealveoli. But usually, theeffecti ve pressure is alveolar pressure}
and when thi s rises above the pressure inside the capillaries, they
diff<.;r!';nce between the.inside and outside of the capillaricsis often called
the transmural pressure.
What is the pressure around the pulmonary art eri es and veins? This can be
considerably less than alveolar pressure. Ast he lung larger blood
vessels are pulled open by the radial tr acti on of the clastic lung parenchyma
which surrounds them (Figures 4-2 and Consequently, th e effect ive pressure
around them is 100\'j in fact there is some evidence that thi s pressure is even less
than the pressure around the whole lung (Intrapleural pressure) . Thi s paradox can
be explained by the mechanical advantagcthat devc10ps when a relat ively r igid
structure like a blood vessel or bronchus is surrounded by a rapidly expanding
elastic mat er ial as lung parenchyma. In any event, oorh-tk arter-ies and
veins' increasetheircal iber as thelung expands.
--. -_.._-_.-' , . .:: ::::;:--.-
Extra-alveol ar
y y y y
t t

t t
Figure 4-2. " Alveolar" and " ext ra-alveola r" vessels. The f i rst are mainly th e cap-
illari es and are exposed to alveolar pressure. The seco nd are pulled open by the
radi al tra ct ion of the surroundi ng lung parenchyma, and the eff ect ive pressure
around t hem is th erefore lower t han alveolar pressure.
The behavior of the capillaries and the larger blood vessels is so different they
are often referred to as alveolar and extra-alveolar vessels (Figure 4, 2). Alveolar
vessels are exposed to alveolar pressure and incl ude the capillaries and the slightly
larger vessels in the corners of the alveolar walls. Their caliber is determined hythe
relat ionship between alveolar pressure and the pressure within them. Exrra-a lveo-
lar vessels incl ude all the arteries and veins that run through the lung parenchyma.
Their caliber is greatly affected by lung volume beca use this determines the ex-
panding pull of the parenchyma on their walls. The very large vessels near the
hil um are outside the lung substance and are exposed [0 intrapleural pressure.
Figure 4-3. Secti on of lung showing many alveo li and an ext ra-alveolar vessel (i n
t hi s case, a smal l vei n) wit h its peri vascular sheath .
Alveolar and Extra-Alveolar Vessels
• Alveolar vessels are exposed to alveolar pressure and are compressed if
thi s increases
• Extra-alveolar vessels are exposed to a pressure less t han alveolar, and are
pulled open by the radial traction of the surrounding parenchyma
Pulmonary Vascular Resistance
:. i , useful to descr ibe the resist ance of a system of blood vessels as follows:
input pressure - output pressure
Vascular resistance = blood flow
number is certain ly not a complete descri ption of the pressure -flow prope r-
ies of the system. For example, th e number usuall y de pends on the magnitude of
the blood flow. Nevert heless, it often allows a helpful comparison of different cir-
culat ions or the same ci rculat ion under different conditions.
\Ve have seen that the tota l pressure drop from pulmonary artery to left atrium
in the pulmonary circulat ion is only some 10 mm Hg against about 100 mm l-lg
tor th e syste mic circulat ion . Because the blood flows through the two circulat ions
are vi rtually identical , it follows that the pulmonary vascular resist ance is only
ne-rent h that of the syste mic ci rcul ati on. The pul monary blood flow is about 6
uers/mm so that, in numbers, th e pulmonary vascular resista nce = (15 -5)/6 or
about 1.7 mm Hg · lircr-
• min." The hi gh resistance of the syste mic circulation
5 largely caused by very muscular art er ioles which allow the regulat ion of blood
w to various organs of the body. The pulmonary circulat ion has no such vessels
and appears to have as Iow a resistance as is compat ible with di str ibuting the
-""'1 in a thin film over a vast area in the alveolar walls.
Although the normal pulmonary vascular resistance is extraordinarily small, it
sa remarkable facili ty for becoming even smaller as the pressure within it rises.
Figure shows tha t an increase in eithe r pulmonary art eria l or venous pressure
causes pulmonary vascular resistance to fall. Two mecha nisms arc responsible for
chis. Under normal conditions, some capillaries are eithe r closed, or open but .
-uh no blood flow. As the pressure rises, t hese vessels begin to conduct blood,
thus lowering the overall resistance. Th is is termed recruitmenr (Figure 5) and is
apparcn tlv the chief mechanism for th e fall in pulmonary vascular resist ance that
as the pulmonary ar tery pressure is raised from low levels. The reason why
some vessels arc unperfused at low perfusing pr essures is not fully understood but
perhaps is caused by random differences in the geometry of the complex net work
Ficure which result in preferen tia l channels for flow.
.Ar hi gher vascular pressures, widening of individual capillary segments occurs.
This increase in ca liber, or distension, is hardly surprising in view of the very th in
membrane whi ch separates th e capillary from th e alveo lar space (Figure 1-1). Dis-
tension is probably ch iefly a ch ange in shape of the cap illar ies from near-flat tened
-: -- - .. ---- -
Cardiologists somet imes express pulmonary vascular resistance in the units dyne ' sec '
• The normal value is then in the region of 100.
40 30
Increasing arterial
Increasing venous
Arterial or venous pressure (em H
0 )
0"---- -"-- ----'-----'
Figure 4-4. Fall in pulmonary vascular resi stance as t he pulmonary arteri al or ve-
nous pressure is rai sed. When the art eri al pr essure was changed, the venous
pressure was hel d constant at 12 em water, and when the venous pressure was
chang ed, t he arte rial pressure was held at 37 em water. (Data from an exci sed
animal lun g preparat lon.)
to more circular. There is evidence that the capillary wall strongly resists stretch-
ing. Dis tension is appare ntly the predominant mechani sm for the fall in pul -
monary vascular resistance at relatively h igh vascular pressures. However, re-
cruitment and distension often occur together.
Another import ant determinant of pulmonary vascular resistan ce is lung vel-
ume. The caliber of rhe extra -alveolar vessels (Figure 4-2) is det ermined by a
balance between various forces. As we have seen, they are pulled open as the
Figure 4-5. Recrui tm ent (openi ng of previously cl osed vessels) and di st ensi on [i n-
crease i n caliber of vessels). These are th e two mechani sms for t he decrease in
pulmonary vascular resist ance t hat occurs as vascular pressure s ar e raised.
lung expands. As a result , the ir vascular resistance is low at large lung vol umes.
On the ot her hand, their walls contain smooth muscle and clastic t issue, whic h
resist distension and tend to reduce t he ir calibe r. Consequently, t hey have a
high resistance when lung volume is low (Figurc Indeed, if the lung is
completely col lapsed. the smooth muscle tone of these vessels is so effective
that the pulmonary artery pressure has to be raised several ce nt imeters of water
above downstream pressure before any flow at all occurs. This is called a critical
opening pressure.
Is the vascular resistance of the capillaries influenced by lung volume?This de-
pends on whether alveolar prcssure changes with respect to the pressure inside the
capillaries, that is, whether their transmural pressure alters. If alveolar pressure
rises with respect to capillary pressure, the vessels tend to be squashed , and their
resistance rises. Thi s usually occurs whe n a normal subject takes a deep inspira-
t ion, because the vascular pressures fall. (The heart is surrounded hy intrapleural
pressure, which falls on inspirat ion.) However, the pressures in the pulmonary
circulation do nor remain steady after such a maneuver. An addi tional factor is
that the caliber of the capillaries is reduced at large lung volumes because of
rhtnni ng of the walls. Thus, even if the trans-
mural pressure of the capillaries is nor changed with large lung inflati ons, their
vascular resistance increases (FigureT iJ)-. - -
-' Because of the TOre of smooth muscle irt determining the caliber of the extra-
alveolar vessels, drugs that cause contract ion of the muscle increase pulmonary
vascular resistance. These include serotoni n, histamin e, and norepinephrine .

==0 ==



t'! 80

50 100 150 200
Lung volume (ml)
Figure 4-6. Effect of lun g volume on pulmon ary vascular resistance when t he
t ransmural pressure of the capillaries is held constant . At low lung volumes, re-
sista nce is high because t he ext ra-alveolar vessels become narrow. At high vol-
umes, .t he capi ll aries are st retched, and th eir cali ber is redu ced. (Data f rom an
animal lobe preparation.)
Pulmona ry Vascular Resistance
• Is normally very small
• Decreases on exercise because of recruitment and disten tion of capillaries
• Increases at high and low lung volumes
• Increases with alveolar hypoxia because of constriction of small pulmonary
These drugs are part icularly effecti ve vasoconstr ictors when the lung volume is low
and the expanding forces on the vessels are weak. Drugs that can relax smooth
muscle in the pulmonary circulation include acet ylcholine and isoprot erenol.
Measurement of Pulmonary Blood Flow
The volume of blood passing through the lungs each minute (Q ) can he calcu-
lated using the Fick principle . This states that the O
consumpt ion per minute
(VOl) is equal (0 the amount of O
taken up by the blood in the lungs per minut e,
Because the 0
concentrat ion in the blood en tering the lungs is evo) and that in
the blood leaving is C <l() z we have ~
, = Q (Cau, - G o,)
C ~ ) l - eVO
Q= -:=--,,=-
VOl is measured by collect ing the expired gas in a large spirometer and measuring
its O
conce nt rat ion. Mixed venous blood is taken via a catheter in the pul-
monary artery, and arterial blood by punct ure of the brach ial or radial art ery. I'ul -
monary blood flow can also be measured by th e indicator dilut ion technique in
which a dye or other indicator is inj ected into the venous circulation and its con-
centration in arterial blood is recorded. Bot h these methods are of great impor-
tance, bur they will not be considered in more detail here because they fall within
the province of cardiovascular physiology.
Distribution of Blood Flow
So far, we have been assuming tha t all parts of the pulmonary circulat ion behave
iden ticall y. However, considerable inequality of blood flow exists within the hu-
man lung. This can be shown bya modi ficati on of the radioactive xenon method
that was used to measure the distribution of vent ilation (Figure 2 ~ 7). For the mea-
suremenr of blood flow, the xenon is dissolved in saline and injected into a pe-
ripheral vein (Figure 4 ~ 7 ) . When it reaches the pulmona ry capillaries, it is
evolved into alveolar gas because of its low solubility, and the distribut ion of ra-
dioact ivity can be measured by counters over the chest during hreathholding.
In th e upright human lung, blood flow decreases almost linearly from bottom
to top, reaching very low values at the apex (Figure 4 ~ 7 ) . This distribution is
OLL- ---'--- ---'--- ---'-- ---'-- -'
Distance up lung (cm)
o 5 10 15 20
Fig ure 4-7. Measurement of t he di str ibut ion of blood fl ow i n t he upright human
lung, using radioacti ve xenon. The dissolved xenon is evolved i nto alveolar gas
f rom the pulmonary capil laries. The unit s of blood fl ow are such that if f low we re
unif orm, all valueswould be 100. Note t he small fl ow at the apex.
affected by change of posture and exercise. When the subject lies supine, the api-
cal : one blood flow increases bur the basal zone flow remains virtually unchanged,
with the result that the distribut ion from apex to base becomes almost uniform.
However, in this posture, blood flow in the posterior {lower or dependent) re-
gions of the lung exceeds flow in the anterior parts. Measuremen ts on subjects sus-
pended upside down show that apical blood lIow mayexceed basal flowin this po-
sit ion. On mild exercise, both upper and lower zone blood flows increase, and the
regional differences become less.
The uneven distribut ion of blood flow can be explained by the hydrostati c
pressure differences within the blood vessels. If we consider the pulmon ary arte-
rial system as a continuous column of blood , the difference in pressure bet ween
the top and bottom of a lung 30 em high will be about 30 em wat er, or 23 mm Hg.
This is a large pressure difference for such a low-pressure system as the pulmon ary
circulat ion (Figure 4-1), and its effect s on regiOnal blood t l o ~ ' areshown in F i g ~
There may be a region at the top of the lung (zone I) where pulmonary artc-
rial pressure falls below alveolar pressure (normally close to at mospheric pres-
sure). If this occurs, the capillaries are squashed flat , and no flow is possible. This
:one 1 does ncr occur under normal condit ions because the pulmonary arterial
pressure is just sufficient to raise blood to the top of the lung but may be present
II the arterial pressure is reduced (following severe hemorrh age, for example) or if
alveolar pressure is raised (during positive pressure ventilation). This vent ilated
but unperfused lung is useless for gas exchange and is called alveolar dead space.
Alveol ar

I '----" I
Arterial Venous
Zone 3
Pa > P", > PA
Figure 4-8. Explanation of th e uneven di stribution of blood fl ow i n the lung, based
on the pressu res affecti ng t he capilla ries .
Farther down th e lung (zone 2) , pulmonary art erial pressure increases because
of the hydrostatic effect and now exceeds alveolar pressure. However, venous
pressure is st ill very low and is less than alveolar p ressure, and thi s leads to re-
markablc pressure-flow cha ract eristics. Under these cond it ions, blood flow is de-
termined by the difference between arterial and alveolar pressures (nor the usual
art erial-veno us pressure difference ). Indeed, venous pressure ha s no influence on
flow unless it exceeds alveolar pressure.
This behavior can be modeled with a flexible rubber tube inside a glass cham-
her (Figure When chamber pressure is greater than downstr eam pressure,
the rubber tube collapses at its downstream end, and the pressure in the tube at
th is poin t limi ts now, The pulmonary capillary bed is clearly very different from
a rubber tube. Ne verthel ess, the overall behavior is similar and is often called the
Starling resistor, sluice, or waterfall effect. Because arterial pressure is increasing
down the zone but alveolar pressure is the same throughout the lung, the pressure
difference responsible for flow increases. In addit ion, increasing recruitment of
capillaries occurs down this zone.
In zone 3, venous pressure now exceeds alveolar pressure, and flow is deter-
mined in the usual way by the arrerial-venous pressure di fference. The increase in
blood flow down thi s region of the lung is apparently caused chiefly by distension
of the capillaries. The pressure withi n them (lying hetween arte rial and venous)
increases down th e zone while the pressure outside (alveolar) remains constant.
Thus, their transmural pressure rises and, indeed, measuremen ts show that their
mean width increases. Recruitment of previously closed vessels may also play
some part in the increase in blood flow down this zone.
Figu re 4-9. Two Star lin g resisto rs, each consisti ng of a th in rubb er t ube inside a
container. When chamber pr essure exceeds downst ream pressure as i n A, f low is
i ndependent of downstream pressur e. However, when downst ream pr essur e ex-
ceeds chamber pr essu re as in B, flow is determi ned by t he upstream-downstream
The scheme shown in Figure summarizes the role played by the capillaries
in deter min ing th e di stri bution of blood £10\,, ', At. low lung volumes, the resistance
of the extra-alveolar vessels becomes important, and a reduction of regional blood
rlow is seen, start ing first at the base of the lung, where the paren chyma is least
expanded (see Figurc 7-8). This region of reduced blood flow is someti mes called
zone 4 and can be explained by the narrowing of the extra-alveolar vessels, which
occurs when the lung around them is poorly inflated (Figure 4-6).
There are other factors causing une ven ness of blood flow in the lung. In some
animals, some regions of the lung appear to have an intrinsically hi gher vascular
resistance. There is also evide nce that blood flow decreases along the acinus with
pet ipheral pans less well supplied with blood. Some measurements suggest that
the periphe ral regions of the whole lung receive less blood flow than the central
regions. Finally, the complex, partl y random arrangeme nt of blood vessels and
capillaries (Figure 1-6) causes some inequalit y of blood flow.
Active Control of the Circulation
\Ve hav e seen that passive factors dominate the vascular resistance and the dis-
tribution o( flow in the pulmonary circulati on under normal conditions. How-
eyer, a remarkable act ive response occurs when the POzof alveolar gas is reduced.
This is known as hypoxic pulmonaT)' vasoconstriction andconsists of contract ion of
smooth muscle in the walls ofthe small arterioles in the hypoxic region. The
cise mechani sm of th is response is not known, but it occurs in excised isolat ed
lung and so does not depend on cent ral ner vous connecti ons. Excised segments
- pulmonary artery can be shown to constrict if the ir environment is made hv-
poxic so that it may be a local act ion of the hypoxia on the artery itself One hy-
pothesis is that cells in the perivascular t issue release some vasoconstricto r sub-
stance in response to hypoxia, but an intensive search for the mediator has not
.' ~ . "
heen successful. Int erest ingly, it is the Po , of the alveolar gas, not the pulmonary
arte rial blood, that chiefly derennines...... th-;; response. This can b e proved by per-
fusing a lung wirh blood of a hi gh Po, whil e keeping rhe alveolar Po, low. Unde r
these cond itions the response occurs.
The vessel wall presumably becomes hypoxic through diffusion of oxygen over
the very shor t distance from the wall to the surrounding alveoli . Recall that a
small pulmonary art ery' is very closely surrounded by alveoli (compare the prox-
imi ty of alveoli to the small pulmonary vein in Figure 4-3) . The stimulus-response
curve of th is constr ict ion is very nonlinear ( Figure 4-10). \X1hen the alveolar po!
is alte red in the region above 100 mm Hg, little change in vascular resistance is
seen. However, when the alveolar P o ~ is reduced below approximately 70 mm Hg,
marked vasoconstriction may cc curvand at a very low Po , the local blood flow
may be almost abolished. -
The mechanism of hypoxic pulmon ary vasoconstrict ion remains obscure in
spite of a great deal of research. Recent studies suggest that inhibit ion of volt age-
gated pot assium channels and membrane depolarization may be involved, lead;
ing to increased calcium ion concentrat ions in the cytoplasm. An increase in
cytopl asmic calcium ion concentrat ion is the major trigger for smooth muscle
Endotheliurn-der ived vasoact ive substances play a role. Nitr ic oxide (l"O)
has been shown to be an endothelium-derived relaxing factor for blood vessels.
Ir is formed hom Larginine via catalysis by endothel ial NO synthase (eNOS)
and is a fina l common pathway for a variety of biological processes. NO act i-
vates soluble guanylate cyclase and increases the synthesis of guanosine 3',5' ~
cycl ic monophosphare (cyclic GMP), which leads to smooth muscle relaxat ion.

60 0
a 50 100 150
Alveolar P02
200 300 500
Figure 4-10. Eff ect of redu cing alveolar P 0 2 on pu lmonary bl ood f low. (Data from
anesth eti zed cat .l - ---
irors of NO synt hase augment hypoxic pulmonary vasoconstricti on in
cal preparat ions, and inhaled NO reduces hypoxi c pulmonary vasoconst ric-
m humans. The required inh aled concentrat ion of i'0 is ext remely low
c t 20 ppm), and the gas is very roxie at high concentrat ions. Disrupt ion of
c. -OS gene has been shown to cause pulmonary hypert ension in animal
. ulrnonarv vascular endothelial cells also release potent vasoconstr ictors
as endorhelin- I (ET-l) and thromboxane A, (TXA,) . Thei r roles in
I r hysioloJ::Yand disease are the subject of intense study. Blockers of en-
neli n receptors have been used clinically to treat patien ts with pulmonary
Hvpoxic vasoconstric t ion has the effect of direct ing bloodflow away from hv-
- regions of lung. These regions may result from bronchial obst ruct ion, and
... vert ing blood flow the deleterious effects on gas exchange are reduced. At
_ alti tude, generalized pulmonary vasoconstric tion occurs, leading to a rise in
nary arterial pressure. But probably the most important situation in which
, mechanism operates is at birth. During fetal life, the pulmonary vascular re-
-AnCe is very high, part lv because of hypoxic vasoconst rict ion, and only some
orthe cardiac output goes through the lungs (see Figure 9,5). When the first
Ah oxygenates the alveoli, the vascular resistance falls dramatically because of
ion of vascular smoot h muscle, and the pulmonary blood flow increases
Jroer act ive responses of the pulmonary circulat ion have been described. A
blood plI causes vasoconstrict ion, especiall y when alveolar hypoxia is pre-
-. There is also evidence th at the autonomi c nervous system exerts a weak
-01. an increase in sympathetic outflow causing st iffening of the walls of the
nary arteries and vasoconstrict ion.
" 'YPoxic Pulmonary Vasoconstriction
• Alveolar hypoxia constricts small pulmonary arteries
Probably a direct effe ct of the low P0
on vascular smooth muscle
Cr tical at birth in the transition from placental to air breathi ng
Directs blood flow away from poorly vent ilated areas of the diseased lung in
' ''e adult
Water Balance in the Lung
;e only 0.3 urn of tissue separates the capillary blood from the air in the lung
_ e 1- 1), the problem of keeping th e alveoli free of fluid is crit ical. Fluid ex-
ec across the capillary endothelium is believed to obey Starling's law. The
e rending to push fluid out of the capillary is the capi llary hydrostatic pressure
.;: the hydrostatic pressure in the interst itial fluid, or Pc - Pi. The force tend,
_ . fu ll fluid in is the colloid osmoti c pressure of the proteins of the blood mi -
char of the prot eins of the interstitial fluid, or 7T
- 'ITt- This force depends on
• ,.
the reflection coefficien t IT, which indicates the effecti veness of the capillary wall
in preventing the passage of protei ns across it. Thus,
net fluid out = K[(P, - P;) - a(", - " ;)]
where K is a constant called the filtra t ion coefficient.
Unfortuna tel y, the pract ical use of this equat ion is limited because of our i g ~
noranc e of many of the values. The colloid osmot ic pressure wit hin th e capillary
is about 28 mm I-Ig. The capillary hydrostat ic pteSSUle is probab ly about halfway
between arterial and venous pressure but is much higher at the bottom of t he lung
than at the top. The colloid osmot ic pressure of the interst it ial fluid is not known
but is about 20 mm Hg in lung lymph. However, thi s value may be higher than
that in the int erst itial fluid around the capillaries. The intersti tial hydrostat ic
pressure is unknown, but some measurements show it is substant ially below at -
mosphe ric pressure. It is probable that the net pressure of the Starling equat ion is
outward, causing a small lymph flowof perhaps 20 ml/hr in humans under normal
condit ions.
Where does fluid go when it leaves the capillaries?Figure 4-11 shows that fluid
which leaks out into the int erst it ium of the alveolar wall tracks thro ugh the in-
terstit ial space to the perivascular and peribronchial space with in the lung. Nu-
merous lymphat ics run in the perivascular spaces, and these help to transport the
fluid to the hilar lymph nodes. In addit ion, the pressure in these perivascular
~ - - - - - - - - - - - - - - - - - - - . . . .
Alveolar space
Alveolar wall
Perivascular space
Figure 4-11. Two pos sible pat hs for f luid that moves out of pul monary capi ll aries.
Flui d t hat enters t he i nt erst itium i ni tia lly f inds it s wa y into the perivascula r and
peribronchial spaces. Later fl uid may cross th e alveol ar wa ll , fil ling alveolar
spaces is low, thus forming a natural sump for the drainage of fluid (compare Fig-
ure The earliest form of pulmonary edema+ is characterized by engorgement
of these peribronchi al and perivascular spaces and is known as intersti tial edema.
The rare of lymph flow from the lung increases considerably if th e capillary
sure is raised over a long period.
In a later stage of pulmonary edema, fluid may cross the alveolar epithel ium
into the alveolar spaces (Figure 4-11). When this occurs, the alveoli fill with fluid
one by one , and because they are then unventilated, no oxygenat ion of the blood
passing through them is possible. What prompts fluid to start moving across into
the alveolar spaces is not known, but it may be that th is occurs when the maxi-
mal drainage rate th rough th e interst itial space is exceeded and the pressure the re
rises too high. Fluid that reaches the alveolar spaces is act ively pumped out by a
sodium, pot assium, ATPase pump in epithelial cells. Alveolar edema is much
more serious than intersti tial edema because of the int erference with pulmona ry
gas exchange.
Other Functions of the Pulmonary Circulation
The chief function of the pulmonary circulati on is to move blood to and from th e
blood-gas barr ier so that gas exchange can occur. However, it has ot her important
funct ions. One is to act as a reservoir for blood. We saw that th e lung has a rc-
markable ability to reduce its pulmonary vascular resistance as its vascular
sures are raised the mechan isms of recruitment and distension (Figure
The same mechanisms allow the lung to increase its blood volume with rel-
at ivelv small rises in pulmonary arterial or venous pressures. This occurs, for ex-
ample, when a subject lies down after standing. Blood then drains from the legs
into th e lung.
Another function of the lung is to filter blood. Small blood thrombi are re-
moved from the circulation before they can reach the brain or other vital organs.
Many white blood cells are trapped by the lung and later released, although the
value of this is not clear.
Metabolic Functions of the Lung
The lung has important metabol ic funct ions in addit ion to gas exchange. A nuru-
ber of vasoact ive substances are metaboli zed by the lung (Table 4-1). Because the
lung is the only organ except the heart that receives the whole circulat ion. it is
uniquely suited to modifying blood-borne substances. A substant ial fract ion of all
the vascular endot helial cells in the body are located in the lung. The metabolic
functions of the vascular endothelium are only briefly dealt with here because
many fall within the province of pharmacology.
T For a more extensive discussion of pulmonary edema, sec the companion volume, JB
West: Pulmonary Pathophysiology- The Essentials , cd 6. Baltimore. Lippincott Wil liams
& Wilkins, 2003.
Table 4-1. Fate of Substances in the Pulmonary Circulation
." .iI
Sub stance
Pepti des
Angiotensin I
Angiot ensin II
Vasopressi n
Seroto nin
Dopami ne
Arachidonic acid metabolit es
Prostaglandin E
and F
Prostaglandin A,
Prostacyclin IPGI,)
Leukot rienes
Converted to angiot ensin II by ACE
Unaffe cted
Up to 80% inact ivat ed
Almost completely removed
Up to 30% removed
Not affected
Not affected
Almost completely removed
Not affected
Not affect ed
Almost completely removed
The only known example of biological act ivatio n by passage through th e pul-
monary circulat ion is the conversion of the relatively inact ive polypept ide, an-
giotensin I, to the potent vasoconstr ictor, angiotensin II. The latt er, which is up
to 50 times more active than its precursor , is unaffected by passage th rough the
lung. The conversion of angiot ensin I is catalyzed by the enzyme, angiot ensin.
convert ing enzyme or ACE, which is located in small pits in the surface of the
capillary endothel ial cells.
Many vasoacti ve substances are completely or parti ally inact ivated during pas·
sage through the lung. Bradykinin is largely inact ivat ed (up to 80%), and the en -
zyme responsible is angiote nsin-convert ing enzyme, ACE. The lung is the major
site of inact ivat ion of serotonin (5· hydroxytrypramine) , but th is is not by enzv-
mati e degradat ion, but by an uptake and storage process (Table 4-1). Some of the
serotonin may he transferred to platelets in the lung or stored in some other way
and released during anaphylaxis. The prostaglandins E
Ez, and F
are also in-
act ivated in th e lung, which is a rich source of the responsible enzymes. Nore-
pinephrine is also taken up by th e lung to some extent (up to 30%). Hi stami ne
appears not to be affected by the intact lung but is readily inact ivat ed by slices.
Some vasoact ive mat erials pass through the lung without significant gain or
loss of act ivity. These include epine phrine, prostaglandins Al and A
giotensin II, and vasopressin (ADH).
Several vasoact ive and bronchoact ive substances are metabolized in the lung
and may be released into th e circulati on under certain condi t ions. Importan t
among these at e the arachidonic acid metabolites (Figure 4-12) . Ar achi doni c
acid is formed through the act ion of the enzyme phospholipase A
on phospho-
lipid bound [0 cell membranes. There are two major synthet ic pathways, the ini -
tial reacti ons being catalyzed by the enzymes lipoxygenase and cyclooxygenase,
respectively. The first produces the leukotrienes which include the medi ator mi g.
inally described as slow-react ing substance of anaphylaxis (SRS-A ). These com-
Membrane-bound phospholipid
1~ Phospholipase A,
Arachidonic acid
Lipoxygenase -7 ~ Cyclooxygenase
Leukotrienes Prostaglandins,
Thrcmboxana A
Figure 4-12. Two pathways of arachidonic acid metabolism . The teukot nenes are
generated by t he Iipoxygena se pat hway, whil e t he prostaglandins and t hrombox-
ane A
come f rom th e cyclo oxygenase pathway.
rounds cause airway constr ict ion an d may have an important role in asthrna. "
Other leukorrienes arc involved in inflammatory responses.
The prostaglandins are potent vasoconstrictors or vasodilators. PGE
plays an
important role in the fetus because it helps to relax the patent ductus arteriosus.
Prostaglandins also affect platelet aggrega tion and are act ive in other systems
such as the kallikrein-kin in clotti ng casca de. T hey also rnav have a role in th e
bronchoconstrict ion of asthma .
The re is also evidence tha t the lung plays a role in the clotting mechani sm of
blooJ under normal and abnormal condit ions. For example, there are a large
number of mast cel ls conta in ing hepar in in the intersti t ium. In addition, the lung
is able to secrete spec ial immunoglobulins, part icular ly IgA, in the bronchial rnu-
cus wh ich contribute to its defenses again st infect ion.
Synthet ic func tions of the lung include the synthesis of phos pholipids such as
dipalmirovl phospharidvlcholine, wh ich is a compone nt of pulmonary surfactant
(see Cha pter 7). Prot ein synthesis is also clear ly important because collagen and
elastin for m the struct ural framework of th e lung. Under some conditio ns, pro-
teases are apparently liberared from leukocytes in th e lung, causing breakdown of
collagen an d elast in, and th is may result in emphysema. Anothe r significant area
is carbohydrate rnetebol isrn, especially th e elabor at ion of mucopolvsaccharides of
bronch ial mucus.
For each quest ion, choose th e one best answer.
1. The ratio of t otal systemic vascular resistance t o pulmonary vascular
resistance is about :
A. 2 : 1
B. 3 : 1
C. 5 : 1
D. 10 : 1
E. 20 : 1
:i: For more details, see JB West: Pulmonary Pathophysiology- The Essentials, cd 6. Hait i
more, Lippi ncott \Vill iams & Wilkins, 2003.
2. All of t he following statements about the ext ra-alveolar vess els of the lung
are true EXCEPT:
A. They are pul led open by radial traction of alveolar wall s.
8. They tend to be narrowed by smoot h mus cle and elast ic t issue in t heir
C. They are exposed to alveolar pressu re.
D. On the arterial side t hey constrict in response to alveolar hypoxia.
E. Their caliber is increased by lung inf lation.
3. A patient wit h pulmonary vascular disease has mean pulmonary arterial and
venous pressures of 55 and 5 mm Hg, respect ively, while the cardiac output
is 3 liters per minute. What is his pulmonary vascular resistance in rnm Hg .
titer " . min .
A. 05
B. 1.7
C 2.5
D. 5
E. 17
4. In a normal subject all of t he following contr ibut e to the fall in pulmonary vas-
cular resistance on exercise EXCEPT:
A. Increase in pulmonary arterial pressure.
B. Increase in pulmonary venous pressure,
C. Recruit ment of pulrnonarv capillaries.
D. Distension of pulmonary capi llaries.
E. Alveolar hypoxia.
5. In a measurement of cardiac out put usi ng t he Fick Principle the O
t rat ions of mixed venous and arterial blood are 16 and 20 mi · 100 mt". re-
spect ively, and t he O
consumpt ion is 300 ml min- ' . The cardiac out put in
liters ' min- 1 is:
A 2.5
B. 5
C. 7.5
D. 10
E. 75
6. In zone 2 of t he lung all of t he fol lowing statements are t rue EXCEPT:
~ A. Art erial pressure exceeds alveolar pressure.
\..- B. Al veol ar pressure exceeds venous pressure.
C. Arterial pressu re exceeds venous pressu re.
D. Blood f low is determined by arter ial pressure mi nus alveolar press ure.
E. Blood flow is determined by arterial pressure mi nus venous pressu re.
7. Pulmonary vascular resistance is reduced by:
A. Removal of one lung.
B. Breathing a 10% oxygen mixtur e.
C. Exhaling from func t ional residual capacity to residual volume .
D. Acut ely increasing pulmona ry venous press ure.
E. Mechanically venti lating t he lung wit h posit ive pressure.
8. All of the following statements about hypoxic pulmonary vasoconstriction
are true EXCEPT:
A. It depends more on the P 0 2 of mixed venous blood than alveolar gas.
B. It is important in the transition f rom placental to air respiration.
C. Its mechanism involves K+ channels in vascular smooth muscle.
D. It partly divert s blood f low from poorly ventilated regions of diseased
E. It is reduced by inhaling low concentrations of nitric oxide.
9. If the pressure in the capillaries and interstitial space at the top of the lung
are 3 and 0 rnrn Hg, respectively, and the colloid osmotic pressures of the
blood and interstitial fluid are 25 and 5 mm Hg, respecti vely, what is the net
pressure in mm Hg moving fluid int o the capillaries?
A 17
B. 20
C. 23
D. 27
E. 33
10. The metabolic funct ions of the lung include all of the foll owing EXCEPT:
A. Convert ing angiotensin-1 to angiotensin-2.
B. Inactivating bradykinin,
C. Removing serotonin. :
D. Removing leukotri enes.
E. Generating erythropoietin.
Ve nti lati on- Perfusi on
How Matching of Gas and Blood Determines Gas Exchange
gen Transport from Air to
ventilat ion
ent ilat i on-Perfusi on Ratio
_ ect of Altering the
entilation-Perfusion Ratio
a Lung Unit
. nal Gas Exchange in the
Effect of Ventilation-Perfusion
Inequality on Overall Gas
Di stributions of Ventilation-
Perfusion Ratios
Ventil ation-Perfusion
Inequality as a Cause of CO
Measurement of Ventilation-
Perfusion Inequality
- 's chapter is devoted to the primaryfunction of the lung, that is gas exchange.
~ rst a theoretical idea! lung is considered. Then we reviewthreemechanisms
, ypoxemia including hvpoventitetion, diffusion limitation andshunt. The diffi-
cult concept 01ventilation-perfusion inequalityis then introduced, and to illus-
rrste this the regional differences of gas exchangein the upright human lung
aredescribed. Then we examine how ventilation-perfusioninequalityimpairs
overet; gas exchange. It is emphasizedthat this is true not only 01oxygen but
3 so carbon dioxide. Methods of measuring ventitstion-pettusioninequalityare
______ . enbriefly discussed.
So far we have cons idered the movement of air to and from the blood-gas inter-
face, the diffusion of gas across it, and the movement of blood to and from the bar-
rier. It would benatural to assume that if all these processes were adequate, normal
gas exchange within the lung would be assured. Unfortuna tely, th is is not so be-
cause the matchingof ventilation and blood flowwithin various regions of the lung
iscritical for adequat e gas exchange. Indeed. mismatching of vent ilation and blood
flow is responsible for most of the defecti ve gas exchange in pulmonary diseases.
In this sect ion we shall look closely at the important (but difficult ) subject of
how the relat ions between vent ilat ion and blood flow det ermi ne gas exchange.
First, however, we shall exa mine two relati velysimple causes of impairment of gas
exchange- hypoventil ati on and shunt. Because all of the se sit uat ions result in
hypoxemia, th at is, in an abnormally low P
in arterial blood. it is useful to take
a prel iminary look at normal O
Oxygen Transport From Air to Tissues
Figure 5 ~ 1 shows howthe Po, falls as the gas moves from the atmosphere in which
we live to the mitochondria where it is ut ilized. The PO
of air is 20.93% of the to-
tal dry gas pressure (that is, excluding water vapor). At sea level, the barometric
pressure is 760 mm Hg, and at the body temperature of 37°C, the water vapor p r e s ~
sure of moist inspired gas (which is fully saturated with water vapor) is 47 mm Hg.
Thus, the Po, of inspired air is (20.93/ 100) X (760 - 47) or 149 mm Hg (say 150).
Figure 5-1 is drawn for a hypotheti cal perfect lung, and it shows that by the
t ime the 0 , has reached the alveoli, the Po, has fallen ro about 100 mm Hg, that
is, by one- third. This is because the PO
of alveolar gas is determined by a balance
Lung and blood
, ;or
Perf ect
•. --")f-------... ----. . -----
Hypoventilati on

Atmosphere - ------- --+_ Mitoch ondri a
Figure 5-1. Scheme of t he O
partial pressures f rom ai r to t issues. The soli d li ne
shows a hypoth eti cal perfect sit uat ion, and t he broken li ne depicts hypoventi la-
ti on. Hypovent il at ion depresses the P02 i n t he alveolar gas and, t herefo re, in the
t issues.
, =
"""''''''' .'f1 rwo processes: the removal of 0, by pulmonary capillary blood on the
;."an:l. and its continual replenishment byalveolar ventilat ion on the other.
..... .v, alveolar ventil .ulon is not continuous hut is breath -by-breath. How-
c fluctuat ion in alveolar Pozwith each breath is only about 3 mm Hg, be-
e tidal volume is small compared with the volume of gas in the lung, so
ress can be regarded as conti nuous.} The rate of removal of O
from the (
_ ~ verned by the O
consumpt ion of the tissues and varies lit tle under rest-
_ =Jldit i?ns. In practice, therefore, the alveolar PO
is largely determined by ) ~
el ot alveolar vent ilati on. The same applies to the alveolar Peo2' which is
ly about 40 mm Hg,
"ben the systemic arterial blood reaches the tissue capillaries, O
diffuses to
tochondria where the Po, is much lower. The "ti ssue" P
probably differs
ierably throughout the body, and in some cells at least , the Poz is as low as
- H ~ . However, the lung is an essential link in the chain of O, transport, and
rease of P
in arterial blood must result in a lower t issue Poz' other thi ngs
rs: equal. For the same reasons, impaired pulmonary gas exchange causes a rise
-;ue Peo,.
r Cau ses of Hypoxemia
• - vpoventit atton
--.. ;fusi on limitation
S unt
entitation-perf usion inequality
e have seen that the level of alveolar POz is determined by a balance between
rate of removal of 0 , by the blood (which is set by the metabolic demands of
tissues] and the rate of repleni shment of Oz by alveolar vent ilation. Thus, if
alveolar vent ilat ion is abnormally low, the alveolar P
falls. For similar rea-
'. the PC- D, rises. This is known as hypoventilati on (Figure 5-1).
Ca uses of hypoven tilat ion include such drugs as morphine and barbiturates
. h depress the cent ral dr ive to the respiratory muscles, damage to the chest
lor paralysis of the respiratory muscles, and a high resistance to breathing (for
mple, very dense gas at great depth underwater) . Hypoven n lanon always
.:aI.. "O an increased alveolar and, the refore, arterial Pear The relati onship be-
-eeen alveolar vent ilat ion and P
was derived on p. 18:
- ·-xK
.ere V c o ~ is the CO
product ion, VAis the alveolar ventilat ion, and K is a con-
scant. This·means that if the alveolar ventilation is halved, the P
is doubled,
" ...lOCe a steady state has been established.
.: ,II
The relat ionship between the fall in POz and the rise in Pco, that occurs in
hypoventil ation can be calcul ated from the alveolar gas equation if we know the
compos ition of inspired gas and th e respirator y exchange ratio R. The lat ter is
given by th e CO, ptoduc t ion/O, consumpti on and is de termined by the
metabolism of the tissues in a steady state. It: is somet imes known as the respira-
tory quot ient . A simplified form of the alveolar gas equation is
PAo, = Plo
- - -R- + F
whe re F is a small correction factor (typically about 2 mm Hg), which we can ig-
Cnot e. This equation shows that if R has its normal value fall in alveo-
lar P02is slightl y greater than is the rise in Peo2J uring hypovent ilation. The full
version of the equat ion is given in Appendix A.
Hypovemilation always reduces the alveolar and art erial P
0 2
except when th e
subject breathes an enriched O
mixtu re. In th is case, the added amount of O
per breath can easily make up for the reduced flowof inspired gas (t ry question 3
on p. 72).
• Always increases the Peo;?
• Decreases the PO
unless additional Oa is inspired
• Hypoxemia is easy to reverse by adding O

Should alveolar ventilat ion be suddenly increased (for exampl e, by volun-
tary hyperven til ati on), it may take several minutes for the alveolar P
o z
Peo2to assume their new steady state values. This is because of the different O
and CO
stores in th e body. The CO
stores are much greater than the O
because of th e large amount of CO, in the form of bicarbonate in the blood and
int ersti t ial fluid (see Cha pter 6). Ther efore, the alveolar Pea , t akes longer to
come to equilibrium, and during the nonsteadv state. the R value of expired gas
is hi gh as th e CO
stores are washed out. Opposite changes occur with the on-
set of hvpoventil at ion .
Figure 5-1 shows th at in a perfect lung, the P
O z
of art erial blood would be the
same as that in alveolar gas. In real life, th is is not so. One reason is that although
the Po, of the blood rises closet and closet to th at of alveolar gas as the blood tra-
verses the pulmonary capillary (Figure 3-3) , it can never quite reach it. Unde r
normal conditions, the P
difference between alveolar gas and end-capillary
blood resulting from incomplete diffusion is immeasurably small but is shown
schemat ically in Figure As we have seen, the difference can become larger
during exercise, or when the blood-gas barrier is th ickened. or if a low O
is inhaled (Figure 3-3B).
1 ~ ? C 9
G"j cal Art
Diffusion Shunt
Atmosphere ) Mitochondria
Figure 5-2. Scheme of O
transfer from air to tissues showing the depression of
art erial P02 caused by diffusion and shunt',
Another reason why the POl of arterial blood is less than that in alveolar gas is
shunted blood. Shunt refers ro blood rhar en ters rhe arrerial system wirhour going
rhrough ventilated areas of lung. In the normal lung, some of the bronchial art ery
blood is collected by the pulmonary veins after it has perfused th e bronchi and its
0 ;2 has been partly deple ted. Another source is a small amount of coronary ve-
nous blood which drains directly into rhe cavity of the left vent ricle through the
Thebesian veins. The effect of the addit ion of th is pootly oxygenated blood is to
depress the arterial P
Some patients have an abnormal vascularconnection be;
[ween a small pulmonary artery and vein (pulmonary arteriovenous fistula). In
patients with heart disease, there may be a direct addition of venous blood to ar-
terial blood across a defect between the right and left sides of the heart.
When the shunt is caused by the addirion of mixed venous blood to blood
draining from the capillaries, it is possible to calculate the amount of the shunt
rlow (Figure 5-3) . The tot al amount of 0 , leaving the system is th e total blood
rlow QT mult ipl ied by the 0 , concentrat ion in t he art erial blood Cao "
or QT XCae,. This must equal the sum of the amounts of 0, in the shunt ed
blood, Qs X Cvo" and end-capillary blood, (QT - Qs) X Cc' 0,. Thus,
QT X Cae, = Qs Xeva, + (QT - Qs) X Cc'o,
Rearranging gives
CC02 - Cao
Cco 2 Cvo2
The 0 , conc entration of end-capillary blood is usually calculated from the alve-
olar P0 2 and the oxygen di ssociation curve (see next chapter).
AS CC'02- Ca02
aT CC'02- CV02
Figure 5-3. Measureme nt of shunt f low. The oxygen carri ed in the arterial bl ood
equals t he sum ofthe oxygen carr ied i n t he capi llary blood and t hat in the shunt ed
blood (see text).
When the shunt is caused by blood tha t does not have the same O
trat ion as mixed venous blood (for example, bronchi al vein blood), it is gene rally
not possible to calc ulate its true magnitude. However, it is often useful to calcu-
late an "as if" shunt, that is, what th e shunt wouldbe if the observed depression of
/ arterial Oz concentration were caused by the addition of mixed venous blood.
'I:-- An important feature of a shunt is that the hypoxemia cannot be abolished by
giving th e subject 100%0, to breathe. This is because the shunted blood that
bypasses vent ilated alveoli is never exposed to the higher alveolar POz so that it
cont inues to depress the art erial P Ol' Howeve r, some elevati on of the art erial P
0 2
occurs because of the 0, added to the capillary blood of vent ilated lung. Most
of the added 0 , is in the dissolved form, rather than attached to hemoglobi n,
because the blood th at is perfusing vent ilated alveoli is nearly fully saturated (see
11 next cha pter) . Giving the subject 100% O
to breathe is mea-
' suremenr of shunt because when the P
0 2
is high, a small depression ofarteri al
Oa conce ntrat ion causes a relativel y large fall in P 0 2 due to the almost flat slope
of th e 0 , dissociat ion curve in th is region (Figure 5-4).
A shunt usually does not result in a raised P
in arterial blood, even though
the shunted blood is rich in COz. The reason is that the chemorecep tors sense
any elevation of arterial PCOz and they respond by increasing the vent ilation.
This reduces the Pco, of the unshunted blood unt il the arterial P
Indeed, in some patients with a shunt , the arterial P
is low because the hy-
poxemia increases respiratory drive (see Chapter 8).
• Hypoxemia responds poorly to added inspired O
•When 100% O
is inspired, the arterial P0
does not rise to t he expected
level- a useful diagnostic test
• If the shunt is caused by mixed venous blood. its size can be calculated
from the shunt equat ion

~ - - ---



dissociation curve
~ ~ ~ - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - - - - ~ }

, '
, '
, ,
, '
, ,
, ,
.Q 10

E 15
o 200 400 600
Figure 5-4. Depression of arterial P02 by shunt during 100% O
breathing. The ad-
dition of a sma ll amount of shunted blood with its low O
concentrat ion greatly
reduces the P02 of arteri al blood . Thi s is because the O
di ssociation curve is
nearjv fl at when the P 0 2 is very hig h.
The Ventilation-Perfusion Ratio
So far we have considered three of th e four causes of hypoxemia: hypoventilat ion,
diffusion, and shunt. We now come to the last cause, whi ch is both the corn-
monest and the most difficult to understand, namely, vent ilat ion-perfusion in-
equality. It turns out th at if ventilat ion and blood flow are mismat ched in various
regions of the lung, impairment of both 0 , and CO, transfer results. The key to
understanding how th is happens is the vent ilat ion-perfusion rat io.
Consider a model of a lung unit (Figure 2-1) in whi ch the uptake of 0 , is be-
ing mimicked using dye and water (Figure 5-5) . Powdered dye is cont inuously
poured into the unit to represent the addi t ion of O
by alveolar vent ilat ion. Wa-
ter is pumped cont inuously through the unit to represent the blood. flow which
removes the O
, A stirrer mixes the alveolar contents, a process normally ac-
complished by gaseous diffusion . The key question is: what determines the con-
centrat ion of dye (or O
) in th e alveolar compartment and, therefore, in the ef-
t1uent water (or blood)?
It is clear that borh the rat e at whi ch the dye is added (ve nt ilat ion) and t n ~ ' ~
tate at whic h water is pumped (bl ood flow) will affect the concentra tion of dye
in the mode l. What may not be int uitively clear is th at the concentra t ion of dye ./
... ...
. ... .. .
~ y : ~ o ; 0
Powdered dye V ~
:\\ .
o 0 0
... .
Concentrati on
Water • • • ••
a _ ----' 0 " 0 0 0 ° '----,--
--)- • 0° • • • • • • • •
_ '----'0'-'- ~ : :
Figure 5-5. Model to il lustrat e how t he vent ilation-perfusion rat io determines t he
P02in a lung unit. Powdered dye is added by venti lat ion at the rate V and removed
by blood f low Q t o represent t he f actors controll ing al veolar P02' The concentra-
t ion of dye is given by V/ Q.
is determined by th e rati o of these ra te s. In other wor ds, if dye is added
at the rate of V gm . min - 1 and wate r is pumped through at Q liters ' min - 1,
the concentr at ion of dye in the alveolar compa rt ment and effluent water is VIQ
gm . liter-

"l- In exactl y the same way, the concentrati on of O
(or bet ter, P
) in any lung
unit is det ermined by the rat io of ventilat ion to blood flow, and not only O
, N
and any other gas that is present under steady state conditions. This is
the reason why th e vent ilat ion-perfusion rati o plays such a key role in pulmonary
gas exchange.
Effect of Altering the Ventilation-Perfusi on
Ratio of a Lung Unit
Let us take a closer look at th e way alterations in the vent ilat ion-perfusion ratio
of a lung unit affect its gas exchange. Figure 5-6A shows the POz and P
in a
uni t with a normal vent ilat ion-perfusion rat io (about I- see Figure 2-1). The
inspired air has a Po, of 150 mm Hg (Figure 5-1) and a P= , of zero. The mixed
venous blood entering the uni t has a Po, of 40 mm Hg and P= , of 45 mm Hg.
The alveolar Po, of 100 mm Hg is derermined by a balance between the addition
of 0, by vent ilation and its removal by blood flow. The normal alveolar P= , of
40 mm Hg is set similarly. •
Now suppose that the vent ilation-perfusion rat io of [he unit is gradually re-
duced by obstrucring its vent ilation, leaving its blood flow unchanged (Figure
5-6B). lr is clear that rhe 0, in the unit will fall and rhe CO, will rise, although
" a,v1
C ". J ,Y"'f' '''"'
\ V\ :.(
= 150 mm Hg 2(
= 0 .J
0 2=
::; "'" ? ,- "'"
CO,= 45
= 40
= 45
= 100
CO,= 40
0 2 = 150
C02= 0
Figure 5-6. Effec t of alte ring the venti lation-perfusion rati o on the P 0 2 and Pee, in
a lung un it .
th e relat ive cha nges of these two are not immediat ely obvious." However, we can
easily predic t what will eventually happe n when the ventilation is completely
abolished (ventil ation-perfusion rati o of zero). Now the O
and CO
of alveolar
gas and end- capillary blood must he the same as those of mixed venous hlood. (In
practice, complet ely obstructed un its eve ntually co llapse, but we can neglect such
long-term effects at the moment.) Note that we are assuming that what happens
in one lung un it out of a very large number does not affect the compos ition of the
mixed venous blood,
Suppose instead that the vent ilat ion-perfusion rat io is increased by gradually
obstruct ing blood flow (Figure 5-6C) . Now the 0, rises and the CO, falls, even-
wally reaching the composit ion of inspired gas when blood flow is abolished
[vent ilat ion-perfusion rat io of infinit y). Thus, as the ventilation- perfusion rat io
of the unit is altered, its gas composit ion approac hes that of mixed venous blood
or inspired gas.
A conve nie nt way of depicting these changes is to use the 0 2-C02 diagram (Pig-
ure 5-7) . In this, POz is plott ed on the X axis, and P
eo z
is plotted on the Yaxis. First,
locate the normal alveolar gas composition, point A (Po, = 100, P
, =40) . If we
assume that blood equilibrates with alveolar gas at the end of the capillary (Figure
3-3), this poi nt can equally well represent the end-capillary blood. Next find the
* The alveolar gas equation is not applicable here because the respiratory exchange ratio
is not constant . The appropriate equation is
IIA 8.63 . R . (Cao, - Cvo,)
ov ~ o --t--__- : ~
Decreasing 'itAIQ
L ~
s I
" .
o 50 100 150
I '
Figure 5-7. OTCO
diagram showing a venti lation-perfusion ratio line. The POz and
Pee, of a lung unit move along thi s line f rom the mi xed veno us point to the inspired
gas point I as its ventilation-perfusion ratio is increased (compa re Figure 5-6).
mixed venous point v(Po, = 40, Peo, = 45). The bar above v means "mixed"
or "mean." Finally, find the inspired point I (POI = 150, Pco, = 0). Al so, note
the similarities betwe en Figures 5-6 and 5-7.
The line joining vto I passing through A shows the cha nges in alveolar gas
(and end-capillary blood) composition that can occur when the ventil ation-
. perfusion ratio is ei ther decreased below normal (A ~ 'V) or increased above nor-
mal (A -e 1). Indeed, thi s line indicates all the possible alveolar gas compositions
·n a lung that is supplied with gas of composit ion I and blood of composit ion v.
~ For example, such a lung could not contain an alveolus with a P
of 70. and P
of 30 mm Hg, because this poi nt does not lie on the ventilation-perfusion line.
However, this alveolar composition could ex ist if the mixed venous blood or in-
spired gas were changed so that the line then passed through this point.
Regional Gas Exchange in the Lung
The way in which the ventilation-perfusion ratio of a lung unit determines its gas
exchange can be graphically illustrated by looking at the differences tha t occur
down the upright lung. We saw in Figures 2 ~ 7 and 4-7 that ventilation increases
slowly from top to bottom of the lung and blood flow increases more rapidly (Fig-
ure 5-8). As a consequence, the ventilation-perfusion ratio is abnormally high at
the top of the lung (where the blood flow is mini mal) and much lower at the bot-
tom. We can now use these regional differences in vent ilat ion-perfusion ratio on an
O, ·CO, diagram (Figure 5-7) to depict the resulting differences in gas exchange.
Figure 5-9 shows the upright lung divided into imaginary horizontal "slices,"
each of which is located on the vent ilation-perfusion line by its own ventilation-
perfusion ratio. This ratio is hi gh at the apex so that thi s point is found toward
the right end of the line, while the base of th e lung is to the left of normal (com-
Blood flow
Vent ilation
Rib number
5 4 3 2
Figure 5·8. Distribut ion of venti lat ion and bl ood flow down t he upright lung (com-
par e Figures 2-7 and 4-7). Note that t he venti lat ion-perf usion rat io decreases
down the lu ng.
l 40
(L8 20
40 60 80 100 120 140
Po.,. mm Hg
Figure 5-9. Result of combi ning t he patt ern of vent i lat ion-perf usion rat io i nequal-
ity shown in Figure 5-8 with th e effects of t hi s on gas exc hange as shown i n Fig-
ure 5-7. Note that th e hi gh ventil ation-perf usio n rat io at th e apex results in a high
P02a nd low PC02t he re. The opposite is seen at th e base.
, .
pare Figure 5-7) . It is clear that the POI of the alveoli (honzonral axis) decreases
markedly down the lung, while the P
(vertic al axis) increases much less.
Figure 5; 10 illustrates t he values that can be read off a diagram like Figure
5-9. (Of course the re will be variat ions between individuals; the chief aim of
this approach is to describe the princi ples underlying gas excha nge.) Note first
that the volume ofthe lung in the slices is less near the apex than the base. Ven-
tilat ion is less at the top than the bottom, but the differences in blood flow are
more marked. Co nsequently, the vent ilat ion-perfusion ratio decreases down the
lung, and all rhe differences in gas exchange follow from th is. Note thar the PO,
..---changes by over 40 rom Hg, while the difference in Pco, between apex and base
-*' I is much less. (Incidentally, the high PO, at the apex probably accounts for the
-' I preference of adult tuberculosis for this region because it provides a more favor,
L.able environment for this organism.) The variation in PN2 is, in effect, by default
because the total pressure in the alveolar gas is th e same throughout the lung.
The regional differences in P
and P
e ol
imply differences in the end-capil-
lary concentrat ions of these gases, which can be obtained from the appropriate
Vol VA
P"" IPc"" IPN2
0 2 !c0 2
pH O
cone. in out
(%) (I/ min) (mm Hg)
(ml/ l00 ml) (ml/min)
/ \ I
7 .24 .07 3.3 132 28 553 20.0 42 7.51 4 8
/ \
, ,
, ,








13 .82 1.29 0.63 89 42 582 19.2 49 7.39 60 39
- ~ ~ -
" V
" : . - - - - ~
- ~ - :=: .. - - -
- - ~ ...
, ,
Figure 5-10. Regional differences in gas exchange down t he nor mal lung. Only
the apical and basal values are shown fo r cl arity.
67 Ventilation-Perfusion Relat ionships
Effect of Ventilation-Perfusion Inequality
on Overall Gas Exchange
- arion curves (Chapter 6). Note the surprisingly large difference
r- the lung, which reflects the considerable variat ion in PUl z of the bl&xi.
minimal contribut ion to overall O
uptake made by the apex can be mainly
ted to the very low blood flow there. The difference in CO, output be- fY{
apex and base is much less because th is can be shown to bernore closelv re-:J
LO a result, th e respiratory exchange rat io (C0
.e) is higher at the apex than at the base. On exercise, when the distribut ion
flow becomes more Uni form, the apex assumes a larger share of the Qz -'£-
the regional differences in gas exchange discussed above are of int erest,
important to the body as a whole is whether uneven vent ilation and blood
arrect the overall gas exchange of the lung, that is, its ability to rake up O
put out CO
, It turns out that a lung wit h ventilation-perfusion inequality is
able to transfer as much a, and CO
as a lung that is uniformly vent ilated
- perfused. ot her things being equal. Or if the same amounts of gas are being
srerred (because these are set by the metabolic demands of the body), the lung
vent ilat ion-perfusion inequality cannot mai nt ain as high an arterial POz or
-an art erial Pco, as a homogeneous lung, again other things being equal.
"he reason why a lung with uneven ventilat ion and blood flow has difficulty
.., nating arterial blood can be illustrated by looking at the differences down
cpnaht lung (Figure 5-11). Here the Po, at the apex is some 40 mm Hg higher
at the base of the lung. However, the major share of the blood leaving the
., comes from the lower zones, where the POz is low. This has the result of de-
ssing the art erial POZ" By contrast , the expired alveolar gas comes more uni-
from apex and base beca use the differences of ventilat ion arc much less
those for blood flow (Figure 5-8). By the same reasoning, th e arterial Pco ,
. be eleva ted because it is hi gher at the base of the lung than at the apex
10 ,-,"re 5-10) .
.An addit ional reason why uneve n vent ilation and blood flow depress th e ar-
al Po , is shown in Figure 5-12. This depicts thr ee groups of alveoli with low,
- .....-alai, and high venrtlation-perfuslon rat ios. The Oz concentrations of the ef-
m blood are 16, 19.5, and 20 ml . 100 ml " , respecti vely. As a result, the
ts with th e hi gh ventilation-perfusion ratio add relati vely little oxygen to the
- ood. compared with th e decrement caused by the alveoli with the low vent ila-
.... vi -perfusion rat io. Thus, th e mixed capillary blood has a lower O
rhan that from units with a normal venrilarion- perfusion rati o. This can be
expla ined by the non linear shape of the oxygen di ssociation curve, which means
mar, although units with a hi gh venrilat ion- perfusron ratio have a relat ively
eh P
' th is docs not increase th e oxygen concentrat ion of t he ir blood very
uch. This addit iona l reason for the depression of Po, docs not apply to the el-
... -arion of th e P
because the CO
dissociation curve is almost linear in the
rking range.
Figure 5-12. Addi tional reason for t he depression of arterial P 0 2 by mismat ching
of vent i lat ion and blood flow. The lung units wit h a high ventilation-perfusion ra-
tio add rel ati vely littl e oxygen to t he bl ood, compared wit h the dec reme nt caused
by alveoli wi t h a low vent i lat io n-perf usio n rati o.
Figure 5-11. Depressi on of the art eri al P0 2 by vent ilat ion-perfusion inequality. In
t hi s diagram of t he upri ght lu ng, only two gro ups of alveoli are shown, one at the
apex and anothe r at the base. The relative sizes of the airways and blood vessels
i ndicate their relat ive vent ilat ions and blood flows. Because most of the blood
comes from the poo rly oxygenated base, depression of the blood P02 is i nevitable.
20.0 19.5
0 2concentration 14.6 16.0
The net result of these mechanisms is a depression of the arterial Pa z below
that of the mixed alveol ar POz- the so-called
In th e normal upright lung, this difference is of tri vial magnitude, being only
about 4 mm Hg due to vent ilat ion-perfusion inequality. Its development is de-
scribed here only to illustrate how uneven ventilat ion and blood flow must result
in depression of the arterial Pozf In lung diseasej the lowering of arterial Poz by
this mechani sm can be extreme.
Distributions of Ventilation-Perfusion Ratios

;;, possible to obtain informat ion about the distributi on of ventilation-p erfusion
in pat ients with lung disease by infusing into a periphera l vein a mixture of
- k ed ine rt gases havin g a range of solubilit ies, and measur ing the concentra-
.'lI'l5- of the gases in art erial blood and expired gas. The details of this technique
roo complex to be described here, and it is used for research purposes rather
in the pulmonary function labora tory. The technique returns a distribut ion
-ennlanor; an d blood flow plotted against vent ilation-perfusion rat io with 50
..;. -enpartrnenrs equally spaced on a log scale.
r i-gure 5-13 sho ws a typical result from a young normal subject. Note that
he ven t ilation and bl ood flow go to compa rtments close to the no rmal
entilat ion-perfusion rati o of abo ut 1.0, and, in part icular, there is no blood flow
- e unvent ilated comp artment (shunt ). The distributions in patients with lung
sease are ofte n very different. An exa mple from a patient wit h chronic bron-
tis and emphysema is shown in Figure 5-14. Note that altho ugh much of the
entilation and blood flow go to compart ments with vent ilation-perfusion ratios
- ar normal, considerable blood flow is going to compa rt ments with ventilat ion-
rerfusion ratios of between 0.03 and 0.3. Blood from these units will be poorly
and will depress the arter ial There is also excessive ventilat ion
- lung units with venulati on-perfusion ratios up to 10. These un its are ineffici ent
- e iminat ing CO
, This part icular patient had art erial hypoxemia but a nor mal
srterial PC02 (see bel ow). Ot he r patterns are seen in ot her types of lung disease.
, ,
+- Ventilation
Blood flow --..
100.0 10.0 1.0
.j ,
No shunt
,/ ,
o 0.0 1
Venti lation-pe rfusion ratio
e 5-13. Dist ri bution of vent ilation-perf usion rat ios in a young normal sub-
ote t he narrow di spersi on and absence of shunt.
No shunt
o 0.01 0. 1 1.0 10.0 100.0
Ventilation-perfusion ratio
Figure 5-14. Di stributi on of vent ilat ion-perf usion rat ios in a patie nt wit h chronic
bronchitis and emphysema. Note part icularly the bl ood fl ow to l ung uni t s with
very low venf ilation-pert usi on rat ios.
J.. ,
Ventilation-Perfusion Inequality
as a Cause of CO
Imagine a lung that is uni formly ventilated and perfused and that is transfer-
ring normal amounts of O
and CO
_ Suppose that in some magical way, the
match ing of ventilation and blood flow is suddenly disturbed while everything
else remains uncha nged. What happens to gas exchange?It transpires that the ef-
feet of this "pure" vent ilation-perfusion inequality (t hat is, everyth ing else hel d
constant ) is to reduce both the O
upt ake and CO, out put of the lung. In other
words, th e lung becomes less efficient as a gas exchanger for bot h gases. Hence,
mismatching vent ilat ion and blood flow must cause bot h hypoxemia and hyper-
capnia (CO, retent ion), other thi ngs being equal,
However, in pract ice, patients with und oubted ven tilat ion-perfusion mequal-
ity often have a normal arterial Pear The reason for this is that wheneve r the
che moreceptors sense a rising P
' there is an increase in vent ilatory drive
(Chapter 8). The consequent increase in vent ilation to the alveoli is usually ef-
fective in returning the arterial Peol to normal. However, such patient s can only
maintain a normal PCOz at the expense of this increased ventilation to their alve-
oli; the ventilation in excess of what they would norma lly require is somet imes
referred to as wasted ,,-'entilarion and is necessary because the lung units with ab-
normally high ventilat ion-perfusion rat ios are inefficient at eli minat ing CO
Such units are said to const itute an alveolar dead space.
enti lat ion-Perfusion Inequality
The vent ilati on-perfusion rat io (VA/OJ determines the gas exchange in any
5 ngle lung unit
• Regional differences of VA/Qin the upright human lung cause a pattern of
reg:onal gas exchange
:.JQ inequality impairs the uptake or elimination of all gases by t he k:ng
A thouqh t he eli minat ion of CO is impaired by VA/a. inequality, this can be
corr ected by increasing the vent ilation to t he alveoli
By contrast, t he hypoxemia resul ting fr om VA/Oinequality cannot be efimi-
nated by increases in vent ilation
Toe different behavior of the two gases results from the different shapes of
~ r j e i r dissoci at ion curves
~ n i l e the increase in vent ilation to a lung with venrilation-pcrfusion in-
lity is usually effective at reducing the arterial P
eo zl
it is much less effect ive
- Increasing the arterial POl" The reason for the different behavior of the two
. lies in the shapes of the CO, and 0 , dissociation curves (Chapter 6) . The
'- :: dissociat ion curve is almost straight in the physiological range, with the rc-
~ that an increase in vent ilat ion will raise the CO
output of lung units with
~ high and low ven tilat ion-pe rfusion rat ios. By contrast, the almost flat top of
~ 0 :: dissociat ion curve means that only units with moderatel y low vent ilation-
cerfusion ratios will benefi t appreciably from the increased ventilat ion. Those
surs that are very hi gh on the dissociat ion curve (high vent ilation-perfusion ra-
- I increase the O
concentrat ion of their effluent blood very litt le (Figure 5- 12).
5C units which have a very lowvent ilat ion-perfusion ratio continue to put out
-sood with an O
concentration close to that of mixed venous blood. The net re-
'lcis that the mixed arterial Po zrises only modestly, and some hypoxemi a always
Measurement of Ventilation-Perfusion Inequality
row can we assess the amount of vent ilat ion-perfusion inequality in diseased
...... '1gs! Radioact ive gases can be used to define topographica l differences in vcnti-
' ion and blood flow in the normal upright lung (Figures 2-7 and 4-7), but in
st pat ients large amounts of inequality exist between closely adjacent units,
.mJ this cannot be dist inguished by counters over the chest. In practice, we rum
- ") indices based on the resulting impairment of gas exchange."
One useful measurement is the altJeolar-arterial POzdifference, obtained by sub-
- acti ng the arterial P0 2 from the so-called "ideal" alveolar P
The latt er is the
which the lung would have if there were no vent ilat ion- perfusion inequality
For more details of this difficult subject, see }B West: Pulmonary Pathophysiology-
TM Essenrials, ed 6. Balti more, Lippincott Williams & Wilkins, 2003.

. J'
.... , ~
and it was exchanging gas at the same respiratory exchange ratio as the reaIl ung.
It is derived from the alveolar gas equation:
PAa, = PI
, - --R- + F
The arterial P
! is used for the alveolar value.
An example will clarify this. Suppose a patient who is breathing airat sea level
has an arterial Po, of 50 mm Hg, an arterial Pco, of 60 mm Hg, and R is 0.8.
Co uld the art erial hypoxemia be explained by hypoventilati on ?
From the alveolar gas equation, the ideal alveolar P
is given by
PAa, = 149 - 0.8 + F = 74 mm Hg
where the inspired Po, is 149 mm Hgand we ignore the small factor F. Thus, the
alveolar-arterial Po, difference is approximately (74 - 50) = 24 mm Hg. This is
abnormally high, and indicates that there is ventijat ion-pertusion inequali ty.
Additional information on the measurement of ventilation-perfusion inequal-
iry can be found in Chap ter 10.
For each Question, choose the one best answer.
1. Aclimber reaches an altitude of 4500 m (1 4,800 ttl where the baromet ric
pressure is 447 mm Hg. The P0
of moist ins pired gas (i n mm Hg) is:
A. 47
B 63
C. 75
D. 84
E. 98
2. A man with normal lunqs and an arterial PC02 of 40 mm Hg takes an over-
dose of barbiturate which halves his alveolar ventilationbut does not change
his CO
out put. If his respiratory exchange rat io is 0.8, 'what will be his arts-
rial P0
(i n mm Hgi approximate ly?
A. 40
B. 50
C. 60
D. 70
E. 80
3. In the situation described in Guestion 2 how much does the inspired O
centration (%1 have to be raised to return the arterial P0
to its original level?
A. 7
B. 11
C. 15
D. 19
E. 23
4. A pat ient with normal lungs but a right-to-Ieft shunt is found at cat heteriza-
tionto have oxygen concentrationsin his arterial and mixed venous blood of
. " and 14 ml . 100 ml "" , respect ively. If t he 0 , concentr ati on of t he blood
",aving t he pulmonary capillaries is calculat ed t o be 20 mi · 100 rnl" , what
5 his shunt as a percentage of his cardiacoutput?
_. 33
) . 53
_. 63
, a climber on the summit of Mt. Everest (baromet ric pressure 247 mm Hg)
-naintains an alveolar POz of 34 mm Hg and is in a steady state (R $: 1), his
3 eolar Peo, (in mm Hg) cannot be any higher t han:
~ . 5
3. 8
C. 10
D. 12
_. 15
_. ~ patient with severe chronic obstructive pulmonary disease, which causes
marked ventilation-perfusion inequality, has an arterial POz of 50 mm Hg and
an arterial Peoz of 40 mm Hg. The Peoz is normal despite the hypoxemia
A. Ventilation-perfusion inequality does not interfere with CO
B. Much of the CO
is carried as bicarbonate.
C. The formation of carbonic acid is accelerated by carbonic anhydrase.
D. CO, diffuses much faster through tiss ue than 0 , .
E. The 0, and CO, dissociation curves have differ ent shapes.
7. The apex of the upr ight human lung compared wit h t he base has a:
A. Higher Po, .
B. Higher ventilation.
C. Lower pH in end-capillary blood.
D. Higher blood f low.
E. Smaller alveol i.
8, If the vent ilation-perfusion ratio of a lung unit is decreased by partial
bronchial obstruct ion while the rest of the lung is unaltered, the aff ected
lung unit will show:
A. Increased alveolar Po, .
B. Decreased alveolar Peo2'
C. No change in alveolar PN,.
D. Rise in pH of end-capillary blood.
E. Fall in oxygen uptake.
9. A patient with lung disease who is breathing air has an arterial Po, and Peo,
of 49 and 48 mm Hg, respect ively, and a respiratory exchange ratio of 0.8.
The approximate alveolar-arterial difference for P0
(inmm Hg) is:
A. 10
B. 20
C. 30
D. 40
E. 50
Gas Transport by the Blood
How Gases Are Moved to the Peripheral Tissues
Acid-Base Status
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Aci dosis
Metabolic Alkalosis
Blood-Tissue Gas Exchange
: ssolved O
- iemcqlobin
:", Dissociation Curve
Dioxi de
=O:! Carriage
:0. Dissociation Curve
e rJ OW consider thecarriageof the respiratory gases, oxygenandcarbon
xide, by the blood. First we look at the oxygen dissociationcurveincluding
e actors that affect the oxygen affinity of hemoglobin. Then we turn to carbon
_ "de which is carried in the bloodin threeforms. Next we consider the acid-
ase status of the blood andthe four principal abnormalities: respiratory acido-
s andalkalosis, and metabolicacidosisand alkalosis. Finallywe briefly look at
-.55 exchange inperipheral tissues.
.. carried in the blood in two forms: dissolved and combined with
J obin.
76 Chapter 6
10 . ~
6 8
14 -
Total O
Dissolved 0 2 ~ .
~ "'f-- 2
- - - - ~ - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - -
20 40 60 80 100 600
Po, (mm Hg)
Figure 6-1. O
di ssoci ation curve (so l i d l ine) for pH 7.4, P C0 2 40 mm Hg, and 3rc
The t otal blood O
concentrat ion i s also shown f or a hemogl obin concent rat ion
15 gm · 100 ml " ? of blood.
Dissolved O
This obeys Henry's law, th at is, the amount dissolved is proportional to the par
tial pressure (Figure 6-1). For each mm Hg of Po, there is 0.003 rnl O, . l ro rnl"
of blood (somet imes writte n 0.003 vol %). Thus, normal art erial blood with a P
of 100 mm Hg contains 0.3 ml 0 , . 100 ml-

It is easy to see that th is way of transport ing O
must be inadequate . Sur
that the cardiac output during strenuous exercise is 30 liters . min-I. Beca
arterial blood contains 0.3 ml 0 , . 100 ml -
blood (t hat is, 3 ml 0, . Iirer "
blood) as dissolved 0 " the roral amount delivered to the t issues is only 30 X 3 =
90 mi · min- I. However, the tissue requirements may be as hi gh as 3C\. "\:
• min - I. Clearly, an additional method of transporting O
is required.
Heme is an iron-porphyrin compound, and th is is joined to the protein glob
which consists of four polypepti de chains. The cha ins are of two types, alpha
beta, and differences in their amino acid sequences give rise to various type-s
human hemoglobin. Normal adult hemoglobin is known as A. Hemoglobin F (;e-
tal) makes up part of the hemoglobin of the newborn infant and is gradually re-
placed over the first year or so of postnaral life. Hemoglobin S (sickle) has valine
instead of glut amic acid in the beta chains. This results in a shift in the dissocia-
t ion curve to the right . but , more important , the deoxygena ted form is poorl y : •
uble and crystallizes within the red cell. As a consequence, the cell shape changes.
from biconcave to crescent or sickle shaped with increased fragility and a ten-
X 100
.mcy to thrombus formation. Many ot her variet ies of hemoglobin have now
ree n described, some with bizarre O
affin it ies. For more informati on about
• moglobin, consult a text book of biochemistry. .,
. .
_.annal hemoglobin A can have its ferrous ion oxidized to the ferric form by
-arious drugs and chemicals, including nitr ites, sulfonamides, and acetanilid.
-:-his ferric fonn is known as methemoglobin. There is a congenital cause in which
:he enzvrnc methemoglobin reductase is deficien t within the red blood cell. An-
• er abnormal form is sulfhemoglobin. These compounds arc not useful for O
Dissociat ion Curve
0: forms an easily reversible combination with hemoglobin (Hb) to give oxvhe-
moglobin: O
+ Hb ~ HbO
. Suppose we rake a number of glass containers
tonomerers), each containing a small volume of blood, and add gas with various
concent rat ions of 0 ,. After allowing ti me for the gas and blood to reach equilib-
rium, we measure the P
of the gas and the O
concen tration of the blood.
Knowing that 0.003 ml 0, will be dissolved in each 100 ml of blood/ mm Hg Po"
'e can calculate the 0 , combined with Hb (Figure 6-1). Note that the amount
carried by the Hb increases rapidly up to a POz of about 50 mm Hg, but
above that the curve becomes much flat ter.
The maximum amount of 0, that can be combined with Hb is called the 0 ,
capacity, This is when all the available binding sites are occupied by 0 " It can be
measured by exposing the blood to a very high Po, (say 600 mm Hg) and sub-
tracting th e dissolved 0 ,. One gram of pure Hb can combine with 1.39* ml Oj
and because normal blood has about IS gm of Hb . 100 ml-
, the 0 , capacity is
about 20.8 ml 0 , . 100 ml-
of blood,
The O
saturation of Hb is the percentage of the available bindi ng sites that
have O
att ached, and is given by
0 , combined with Hb
0 , capacity
The 0 , sat urat ion of arterial blood with Po, of 100 mm Hg is about 97.5%, while
that of mixed venous blood with a Po, of 40 mm Hg is about 75%.
The change in Hb from the fully oxygena ted state to its deoxygenated state is
accompanied by a conformational change in the molecule. The oxygenated form
is the R (relaxed) state, while the deoxy form is the T (tense) state. It is important
(0 grasp the relat ionships between P Ol ' O
saturat ion, and 0 2concentration (Fig.
ure 6·2). For example, suppose a severely anemic pati ent with an Hb concentra-
rion of only 10 gm : 100 ml-
of blood has normal lungs and an arterial Po, of 100
mmHg. This panem'sOj capaciry will be 20.8 X 10/ 15 = 13.9 ml- 100 ml-
, The
pat ient's O
saturation will be 97.5% (at normal pH, P
and tempe rature), but
*Some measurements give 1.34 or 1.36 ml. The reason is that under the normal condi-
tions of the body, some of the hemoglobin is in forms such as methemoglobin that can,
not combine with Oz.
,cHb = 20
,cHb = 15
c (HbCO = 33%)
......~ . _ - - - - - - - - - - - -
. ~
\. Hb = 10
50 a
0 0
0 30 60 90 120
PO, (mm Hg)
Figure 6-2. Effects of anemia and polycyt hemia on O
concentration and satura-
ti on. In addit ion, t he broken line shows t he O
dis sociati on curve when one-th i rd
of the normal hemoglobin is bound t o CO. Note that t he curve i s shift ed to the left .
the 0 , combined with Hb will be only 13.5 ml . 100 ml -
Dissolved 0 , will con-
tribute 0.3 ml, giving a total 0, concentrat ion of 13.8 ml . 100 ml-
of blood. In
general, the oxygen concentration of blood (in ml 0 , . 100 ml-
blood ) is
given by
Sat )
1.39 X Hb X 100 + 0.003 Po,
where Hb is th e hemoglobin concentrat ion in gm ' 100 rol-
, Sat is the percent-
age saturat ion of the hemoglobin, and P
is in mm Hg.
The curved shape of the O
dissociat ion curve has several physiological ad-
vantages. The flat upper portion means that even if the POl in alveolar gas falls
somewhat , loading of 0 , will be little affected. In addition, as the red cell takes
up 0 , along the pulmonary capillary (Figure 3-3), a large parrial pressure differ-
ence between alveolar gas and blood continues to exist when most of the O
been transferred. As a result , the diffusion process is hastened. The steep lower
part of the dissociat ion curve means that the peripheral tissues can withdraw large
amounts of O
for only a small drop in capillary P
This maintenance of blood
POz assists the diffusion of O
into the t issue cells.
Because reduced Hb is purple, a low arterial O
saturat ion causes cyanosis .
However, this is not a reliable sign of mild desaturarion because its recognition
depends on so many variables, such as lighting conditions and skin pigment ation.
Because it is the amount of reduced Hb that is important , cyanosis is often marked
when polycythemia is present but is difficult to detect in anemic pat ient s.
The O
dissociation curve is shifted to the right , i.e.. the O
affinity of Hb is
reduced, by an increase in H+ concentration, P
, temperature, and the con-
1 0 0 ~ 2 0 0 3 ~ ~ o
o Temp
P 100
100 80
1 0 0 ~
0;'; 7.2
S;t 7.4
p 100
60 40 20
Po, {mm Hg)
Figure 6-3. Rightward shift of the O
dissociati on curve by i ncrease of H+, P ~ 0 2 '
t emperat ure, and 2,3-dipho sphoglycerate (DPG) .


centrat ion of 2.3-diphosphog lyceratc in the red cells (Figure 6-3). Opposite
changes shi ft it to the left. Most of the effect af P
, . which is known as the Bahr
effect, can be attributed to its act ion on H+ conc entra t ion. A rightward shift
means more unloading of O
at a given P
in a tissue capillary. A simple way to
remember these shifts is th at an exercising muscle is ad d, hypercarbic, and hot,
and it benefits from increased unl oading of O
from its capillaries.
The environment of the Hb with in the red cell also affects the O
dissociat ion
curve. An increase in 2.3-diphosphoglycerate (DPG) . which is an end-product of
red cell metabolism, shifts the curve to the right. An increase in concentrat ion of
th is material occurs in chronic hypoxia, for example . at hi gh alti tude or in the
presence of chronic lung disease. As a result, the unl oading of O
to peripheral
rissues is assisted. By conrrast , stored blood in a blood ban k may be depleted of
Oxygen Dissociation Curve
• Usef ul "anchor" points: POz 40, SOz 75%; P0
100, SOz 97%
• Curve is right-shifted by increases in temperat ure, Pcoz, H+, 2.3 DPG
• Small addition of CO to blood causes a left shift
: J ~ ; ;
" - ' ~ J !
2,3-DPG, and unloading of 0 , is therefore impaired. A useful measure of the po-
sition of the dissociat ion curve is the PO l for 50% O
saturation. This is known as
the Pso. 111C normal value for human blood is about 27 mm Hg.
Carbon monoxide interferes with the O
tr ansport function of blood by corn-
bining with Hb to form carboxyhemoglobin (COHb). CO has about 240 ti mes
the affinity of O
for Hb; t his means t hat CO will combine with the same amount
of Hb as O
when t he CO partial pressure is 240 times lower. In fact , t he CO di s-
sociation curve is almost ident ical in shape to the O
dissociation curve of Figure
6-3, except that the Fco axis is greatl y compressed. For example, at a f' co of 0. 16
mm Hg, 75% of the Hb is combined wit h CO as COHb. For this reason, small
amounts of CO can t ie up a large proportion of the Hb in the blood, thus making
it unavailable for O
carriage. If th is happens, t he Hb concentration and P01 of
blood may be normal, but its O
concent ration is grossly reduced. The pre sence of
COHbalso shifts the 0 , dissociat ion curve to the left (Figure 6-2) , thus int erfer-
ing with the unl oading of 0 , . This is an additional feat ure of the toxic ity of CO.
Carbon Dioxide
is carried in t he bl ood in t hree forms : di ssolved, as bicarbonate, and in com-
bination with prot eins as carbamino compounds (Figure 6-4).
Dissol'ved COb like 0
obeys Henry's law, but CO
is about 20 t imes more sol-
ub le th an Oz. As a result, dissolved CO
plays a significant role in its carriage in
100% '-7",
Dissolved 5
0% '---=---l
Figure 6-4. The first column shows t he proportions of th e to t al CO
co nce ntrat ion
in art erial blood. The second column shows the proportions t hat ma ke up the ve-
no us-arte ria l difference,
? Dissolved ? Dissolved
+ H
0 _ H
CO, %
.j. %
m "6


C. CI-

Tissue Plasma Red blood cell
Figure Scheme of the uptake of CO
and liberation of O
in systemic capillar-
-es. Exactly opposite events occur i n the pulmonary capilla ries.
tha t abour 10% of rhe gas rhar is evolved into the lung from rhe blood is in the
dissolved form (Figure 6-4).
Bicarbonate is formed in blood by the follow ing sequence:
CO, + H
0 CA H, C0
"" H+ + HCO,
The first reaction is very slow in plasma but fast within the red blood cell because
of the presence there of rhe enzyme carbonic anhydrase (CA). The second reac-
tion, ionic dissociation of carbonic acid, is fast without an enzyme. When the
concentration of these ions rises within the red cell , HC0 3" diffuses out but H+
cannot easily do this because the cell membrane is relative ly impermeable to
cations. Thus, to maintain electrical neutrality, CI- ions move into the cell from
the plasma, rhe so-called chloride shift (Figure 6-5). The movemenr of chloride is
in accordance with the Gibbs-Donnan equilibrium.
Some of the H+ ions liberar ed are bound ro reduced hemoglobin;
H+ + HbO, "" H\ 0,
(J -t- -reC'
Thi s occurs because reduced Hb is less acid (that is, a bener proton acceptor}
than rhe oxygenared form. Thus, rhe presence of reduced Hb in the peripheral
blood helps with the loading of CO" whi le rhe oxvgenation that occurs in the
pulmonary capillary assists in rhe unl oading. The fact that deoxygenarion of rhe
blood increases its abili ry ro carry CO
is known as rhe Haldane effect.
These events associated with the uptake of CO
by blood increase the osmo-
lar content of the red cell, and, consequently, water ente rs the cell, thus increas-
ing its volume. When rhe cells pass through rhe lung, rhey shrink a littl e.
Carbamino compounds are formed by the combinat ion of CO
with terminal
amine groups in blood proteins . The most important protein is th e globin of
hemoglobin: Hb · NH, + CO, -.= Hb·NH·COOH, giving carbamino -
hemoglobin . This reacti on occurs rapidly without an enzyme, and reduced Hb
can bind more CO, as carbamino-hemoglobin tha n HbO, . Thus, again unload-
ing of 0, in peripheral capillaries facilitates the loading of CO" while oxygena-
tion has the opposite effect .
The relat ive contribut ions of the various forms of CO
in blood to the total (
concentration are summarized in Figure 6;4. Note that the great bulk of the
is in the form of bicarbona te. The amount dissolved is small, as is that in
the form of carbamino- hemoglobin. However, these proporti ons do not reflect
t he changes that take place when CO, is loaded or unloaded by the blood. Of the
total venous-arter ial difference, about 60% is attributable to HCO j , 30% to car;
bamino compounds, and 10% to dissolved CO, .
Dissociation Curve
The relat ionship between the P
, and the total CO, concentrat ion of blood
is shown in Figure 6;6. Note that the CO
dissociation curve is much more
linear than is the O
dissociat ion curve (Figure 6;1). Note also that the lower
the sat uration of Hb wit h Oz, th e larger th e CO
concentrat ion for a given
, . As we have seen, this Haldane effect can be explained by the bett er abil-
ity of reduced Hb to mop up th e H+ ions produced when car bonic acid dtssoci-
ares, and the great er faci lity of reduced Hb to form carbamino-he moglobin.
Figure 6 ~ 7 shows that the CO
dissociat ion curve is considerably steeper than
that for 0 , . For example, in the range of 40 to 50 mm Hg, the CO, conccntra-
Figure 6-6. CO
di ssoci ati on curves for blood of different O
sat urat ions. Not e t hat
oxygenated blood carries less CO
for t he same PC0 2' The inset shows t he " phvs-
iological " curve between arterial and mixed venous bl ood.
partial pressure (mm Hg)
80 60 40 20 o
I 40

8 20
Acid-Base Status
Figure 6·7. Typical O
and CO
dissociation curves plotted with t he same scales.
l ate that the CO
curve is muc h steeper.
0 2
20 40 60 80

and CO
partial pressure (mm Hg)
Gas Transport by the Blood

E ::=- 40
1l E
0 0
0 ":::=
o.s 20
Carbon Dioxide Dissociation Curve
• CO
carriedas: dissolved, bicarbonate, carbamino
• CO
CUNe is steeper andmore linear than the O
• CO
curve is right-shifted by increasesin S02
[ion changes by about 4.7, compared with an 0
concentration of only about
1.7 mlllOO m!. This is why the Po, difference between art erial and mixed
venous blood is large (typically about 60 mm Hg) but the P
, difference is
small (about 5 mm Hg).
(W ) X (HCO
the law of the mass an ion gives the dissoc iation constant of carbonic acid
K,.:, as
Th e transport of CO, has a profound effect on the acid-base stat us of the blood
and rhe body as a whole. The lung excret es over 10,000 mEq of carbonic acid per
day compared with less than 100 mEq of fixed acids by the kidney. Therefore, bYJ --
altering alveolar ventilation and thus the elimination of CO
, the body has great
control balance. ThEf siiDJ ed wll f be treated only briefly here
because it overlaps the area of renal physiology.
The pH resulting from the solut ion of CO, in blnod and the consequen t dis-
sociation of carbonic acid is given by the Henderson-Hasselbalch equation. It is
derived as follows. In the equation
"" H+ + HCO
. , . , ~
_ ·,1,
Because the concentration of carbonic acid is proportional to the concentrati
of dissolved carbon dioxide, we can change the constant and write
(W) X (HCO
(CO, )
Taking logarithms
(HCO, )
log KA = log (H+) + log (CO, )
(HCO, )
- log (H+) = - log KA + log (CO, )
Because pH is the negative logarithm
pH = pKA + log (CO,)
Because CO, obeys Henry's law, the CO, concent ration (in mmol/liter) can
replaced by (Pc'Oz X 0.03). The equat ion then becomes
plI = pKA + log 0.03 P
The value of pK
is 6. 1, and the normal HCO, concentrat ion in arterial blood
24 rnmohluer. Substituting gives
pH = 6. 1 + log 0.03 X 40
= 6. 1 + log 20
= 6. 1 + 1.3
pH = 7.4
Note that as long as the ratio of bicarbonate concentration to (Pa.::h X O.C~
remains equal to 20, the pH will remain at 7.4. The bicarbonate concenrrat i
determined chiefly by the kidney and the Pco, by the lung.
The relationships bet ween plI, P
e ol
. and HC0
are conveniently shown
a Davenpor t diagram (Figure 6-8) . The two axes show HCO, and pl-l, and lin
of equal P<"' 'Ozsweep across the diagram. Normal plasma is represented by point A.
The line CABshows the relat ionship between HCO, and pH as carbonic acid is
added to whole blood, that is, it is part of the t itrat ion curve for blood and is called
the buffer line . The slope of this line is steeper than that measured in plasma sep-
arated from blood because of t he presence of hemoglobin, which has an addi-
tional buffering action. The slope of the line measured on whole blood in ti rro b
usually a littl e different from that found in a pati ent because of the buffering ac-
tion of the interstitial fluid and ot her body tissues.
Figure 6-8. Davenport diagram showing the relationships among HCO"3, pH, and
Peo2. A shows the normal buffer line BAC. B shows t he changes occurring in res-
piratory and metabolic acidosis and alkalosis (see text). The vertical distance be-
tween buffer lines is the base excess.
Gas Transport by the Blood 85
'2 40
6.8 7.0 7 .2 7.4 7.6 7.8 8.0
pH units
.. •
"' E 20
7.1 7. 4 7.7

Acidosis Alkalosis
-.. ...
. .
- -",l
If the plasma bicarbonat e concent ration is altered by th e kidney, the huffe
line is displaced. An increase in bicarbonate conce nt rat ion displaces the buffe
line upward as shown. for example. by line DE in Figure 6 ~ 8 . In this case, the
excess is increased and is given by the vert ical distance between the two butte
lines DE and BAe. By cont rast, a reduced bicarbonate conce ntration displac
the buffer line downward (line GF). and there is now a negative base excess,
base deficit.
The ratio of bicarbonate to P= , can bedisturbed in four ways: both Peo, an
bicarbonate can be raised or lowered. Each of t hese four disturbances gives rise t
a characteristic acid-base cha nge.
Respiratory Acidosis
This is caused by an increase in P
which reduces the HC0 3"/P
co z
rat io and
thus depresses the pH. This corresponds to a movement from A to B in Figure 6 ~
8. Whenever the Pco- rises, the bicarbonate must also increase to some exrent
because of dissociation of the carbonic acid produced. This is reflected by rh
left upward slope of the blood buffer line in Figur e 6-8. However. rh
rat io HC0 1/ P
eo z
falls. CO
retent ion can be caused by hvpovenril ar ion
vent ilat ion- perfusion inequality.
If respiratory acidosis persists. the kidney responds byconservi ng HCO
. It is
prompted to do this by the increased P
, in the renal tubular cells, whi ch the
excrete a more acid urine by secret ing H+ ions. The H+ ions are excreted
P0 4" or N H ~ ; th e HCO
ions are reabsorbed. The result ing incre ase in
plasma HCO, then moves the HCO, / Pco, rat io back up toward its norma
level. This corresponds to t he movement from B to D along the line Pco. = 6C
mm Hg in Figure 6 ~ 8 and is known as compensated respirawry acidosis. Tvpical
eve nts would be
~ 6.1 + log 15.6 = 7.29
(Respiratory acidosis
pH = 6. 1 + log 0.03 x 40
pl-l ~ 6.1 + log 0.03 x 60
~ 6. 1 + log 20 = 7.4 (Normal
pH = 6. 1 + log 0.03 X 60 ~ 6.1 + log 18.3 = 7.36
(Compensated respiratory acidosis
The renal compensat ion is typically not complete. and so the pH does not full
return to its normal level of 7.4. The extent of the renal compensat ion can be de-
termined from the base excess. that is, the vert ical distance between the butter
lines IlA and DE.
Respiratory Alkalosis
This is caused by a decrease in P
eo z
• which increases the HCOl /Pc'Oz rat io and
thus elevates the pH (movement from A to C in Figure 6 ~ 8 ) . A decrease in Po:>:
is caused by hypervent ilat ion, for example, at high alt itude (see Chapter 9). Re-
nal compensat ion occurs by an incr eased excret ion of bicarbonate, th us returning
the HCOj /P
, rati o back toward normal (C to F along the line Pco, = 20 mm
Hg) . After a prolonged stay at hi gh alti tude, the renal compensat ion may be
nearly complete . There is a negative base excess, or a base defici t.
Metabolic Acidosis
In this context , "met abolic" means a primary change in H C O ~ , that is, the nu-
merator of the Hend erson-Hasselbalch equat ion. In metabolic acidosis, the rat io
of HCO j to Pco, falls, thus depressing th e pH. The HCO j may be lowered by
the accumulation of acids in th e blood, as in uncontrolled diabetes mellitus. or af-
ter t issue hypoxia, which releases lact ic acid. The corresponding change in Figure
6-8 is a movement from A toward G.
In thi s instance, respiratory compensation occurs by an increase in ventilat ion
that lowers th e P
and raises the depressed HCO j /PeGI rat io. The st imulus to
raise the ventil at ion is chiefly the act ion of H + ions on the peripheral chemore-
ceptor> (Chapter 8). In Figure 6-8, th e point moves in the direct ion G to F (al-
though not as far as F). There is a base defici t or negati ve base excess.
Met abolic Alkalosis
Here an increase in HCO j raises the HCO"J/PCUI rat io and, thus, the pH. Ex-
cessive ingest ion of alkalis and loss of acid gastr ic secret ion by vomit ing are
causes. In Figure 6 ~ 8 , t he movement is in the direction A to E. Some respirator y
compensation sometimes occurs by a reduct ion in alveolar vent ilation th at raises
the P
,. Poi nt E then moves in the direct ion of D (although not all the way).
However. respiratory compensation in met abolic alkalosis is often small and may
be absent. Base excess is increased.
Note th at mixed respirato ry and metabol ic distur bances often occur, and it
may then be difficult to unravel the sequence of events.
Four Types of Acid-Base Disturbances
pH = pK+ log 0.03 Peo,
Primary Compensation
Peo" HCO"
Metabolic HCO, 1 Peo, 1
Respiratory Pco, 1 HCO, J.
oft en none
Blood-Tissue Gas Exchange
0 , and CO, move between the systemic capillary blood and the tissue cells by
simple diffusion, just as they move bet ween the capillary blood and alveolar gas
in the lung. We saw in Chapter 3 that the rate of transfer of gas th rough a tissue
sheet is pro port ional to th e tissue area and th e difference in gas part ial pressure
between the two sides, and inversely proport ional to the th ickness. The thickness
of the blood-gas barrier is less than 0.5 p.rn, but the distance between open capil -
laries in rest ing muscle is on the order of 50 urn. During exercise, when the O
consumpt ion of the muscle increases, addit ional capillaries open up. thus reduc-
ing the diffusion distance and increasing the area for diffusion . Because CO
fuses about 20 times faster than 0 , through t issue (Figure 3- 1), eliminat ion of
CO, is much less of a probl em than is 0, delivery.
The way in which the P
falls in tissue between adjacent open capillaries is
shown schematically in Figure 6-9. As the 0, diffuses away from the capillary, it is
consumed by t issue, and the Pazfalls. In A, the balance between O
consumpt ion
and delivery (determined by the capillary Po, and the int ercapillary dist ance) re-
sults in an adequate P
in all the tissue. In B. the int ercapillarydistance or the O
consumption has been increased until the P
at one point in the tissue falls to
zero. This is referred to as a critical situat ion. In C, there is an anoxic region where
aerobic (that is, O
utilizing) metabolism is impossible. Under these condit ions,
the t issue turn s to anaerobic glycolysis with the formati on of lactic acid.
There is evidence that much of the fall of PO
in peripheral t issues occurs in
the immediate vicinity of the capillary wall and that the POz in muscle cells, for
example, is very low (1 to 3 rom Hg) and nearl y uniform. This pat tern can be ex-
plained by th e presence of myoglobi n in the cell that acts as a reservoir for O
enhances its diffusion within the cell.
How low can the t issue P
fall before O
utilization ceases?In measurement s
on suspensions of liver mitochondria in virro, O
consumpt ion continues at the
same rate until the Poz falls to the region of 3 mm Hg. Thus, it appears that the
purpose of the much hi gher POl in capillary blood is to ensure an adequat e p r e s ~
sure for diffusion of Oj to the mitochondria and that at the sites of O
utili zati on
the Po, may be very low.
Cap Tissue Cap
J l ~ l u r u
A B c
Figure 6-9. Scheme showi ng the f all of P02 between adj acent open capilla ries. In
A, oxygen deli very is adequate; i n B, criti cal ; and in C, inadequate for aerobic
metabolism i n t he cent ral core of t issue.
An abnormall y low P Ol in ti ssues is ca lled t issue hypox ia. Th is is freq uently
caused by low Oz delivery, which can be expressed as the cardi ac output multi-
plied by the arterial Oa concentrat ion, or QX Cao
. The factors that det ermine
Cao, were discussed on page 65. Tissue hypoxia can be due to (l) a low P Ol in ar-
rerial blood caused, for example, by pulmonar y disease ("hypoxic hypoxia"); (2)
a reduced ability of blood to carry O
as in anemia or carbon monoxide poiso ning
("anemic hypoxia") ; or (3) a reduct ion in t issue blood flow, either generalized, as
in shock, or because of local obstru ction ("circulatory hypoxia"). A fourth cause
is some toxic substance tha t interferes with the abili ty of the ti ssues to utilize
available O
("h istotoxic hypox ia"). An example is cyanide, wh ich prevents the
use of O
by cytochrome ox idase. In thi s case, the O
concentr at ion of venous
blood is high , and the O
consumption of the ti ssue extremely low because these
are rel ated by the Fick princi ple as applied to peripheral O
consu mpt ion. Table
6 ~ 1 summar izes some of th e features of the different types of hypoxemia and ti s,
sue hypoxia.
Table G
. Features of Different Types of Hypoxemia or Tissue Hypoxia"
Admin istrati on
PA02 PAco2 Pao2 Paco2 Cao
5 a02 PV0
Helpful 7
Hypoventilation I 1 1 Yes
Diffusion impairment 0 0 0 Yes
Shunt 0 0 0 Yes-
'it,,;oinequality Varies l or 0 l or 0 Yes
Anemia 0 0 0 0 0 Yes-
CO poisoning 0 0 0 0 0 " Yes-
Cyanide poisoning 0 0 0 0 0 0 1 No
"'0, normal ; l lncreasect l decreased.
"Of some (but limit ed) value because of increased dissolved oxygen
"lt 0 2 saturat ion is calculated for hemoglobin not bound t o CO.
For each quest ion, choose t he one best answer.
1. The presence of hemoglobin in normal arterial blood increases its oxygen
conc entrat ion approximately how many t imes?
A. 10
B. 30
C. 50
D. 70
E. 90
2. An increase in w hich of th e f ol low ing increases t he 0, af fi ni ty of
A. Tem perature.
B. PCO, .
C. H+ concent rat ion. .l
D. 2,3 DPG.
E. Carbon monoxide added to t he blood.
3. A patient w it h carbon monoxide poisonin g is treat ed wit h hyperbar ic oxygen
that increases t he arterial Po, to 2,000 mm Hg. The amount of oxygen dis-
solved in the art er ial blood (in ml . 100 rnt") is:
A. 2
B. 3
C. 4
D. 5
E. 6
4. A pat ient wi th sever e anemia has normal lungs. Which of t he fo llowi ng is
most likel y to be FALSE?
A. Normal arterial Po
B. Normal arterial O
C. Low arterial O
D. Low oxygen concentration of mixed venous blood.
E. Normal tissue Po
5. Al l of the following statements are t rue about acut e carbon monoxide poi-
soning EXCEPT:
A. Reduced arterial Po, .
B. Reduced oxygen concentrat ion of art erial blood.
C. Redu ced oxy gen concentration of mixed venous blood.
D. 0 , di ssociat ion curve is shifted to the left.
E. Carbon mono xide is colorless and odor less.
6. The laboratory repo rt s th e f ollowing arterial blood gas value s in a pat ient w it h
severe lung disease w ho is breath ing air: Po, 60 mm Hg, Peo, 110 mm Hg,
pH 7.20. All of t he f ollowi ng statement s are true EXCEPT:
A. Pat ient has hypoxemia.
B. Patient has seve re CO
retent ion.
C. There is a respiratory acidosis.
D. The respiratory aci dosis is part ially compensated.
E. The values for P0
and Peo2 are internally consist ent.
7. Most of the carbon dioxide t ransported in t he blood is in the form of:
A. Dissolved.
B. Bicarbonate.
C. Attached to hemoglobin.
D. As carbami no compounds.
E. Carbonic acid.
8. A patient with chronic lung disease has arterial P0
and Peo2values of 50
and 60 mm Hq, respect ively, and a pH of 7.35. How is his acid-base status
best described?
A. Normal.
B. Partially compensated respiratory alkalosis.
C. Partially compensated respiratory acidosis.
D. M etabolic acidosis.
E. Met abolic alkalosis.
9. The P0
(in mm Hg) inside skeletal muscle cells during exercise is closest to:
A. 3
B. 10
C. 20
D. 30
E. 40
10. A patient wi th chronic pulmonary disease undergoes emergency surgery.
Post operatively t he art erial Po,. Pea, and pH are 50 mm Hq. 50 mm Hg and
7.20. respect ively. How would the acid-base status be best described?
A. Mixed respiratory and metabolic acidosis.
B. Uncompensated respiratory acidosis.
C. Fullycompensated respiratory acidosis.
D. Uncompensated metabolic acidosis.
E. Fully compensated metabolic acidosis.
11. The laborat ory provides the following report on arter ial blood from a patient:
Pea, 32 mm Hg, pH 7.25. HCO- 3 concentration 25 mmol . 1-
. You conclude
t hat t here is:
A. Respiratory alkalosis with metabolic compensation.
B. Acute respiratory acidosis.
C. Metabolic acidosis wi th respiratory compensat ion.
D. Metabolic alkalosis with respiratory compensation.
E. A laboratory error.
12. A pat ient with shortness of breath is breath ing air at sea level and an arterial
blood sample shows Po, 90 mm Hq. Pco, 32 mm Hg, pH 7.30. Assuming
that the respiratory exchange ratio is 0.8. the se data indicate:
A. Primary respiratory alkalosis wi th met abolic compensation.
B. Normal alveolar-arter ial P0
difference .
C. Arterial O
saturat ion < 70 % .
D. The sample was mistakenly taken from a vein.
E. Partially compensated metabolic acidosis.
Mechanics of Breathing
How the Lung Is Supported and Moved
scles of Respi rat ion
sti c Propert ies of the Lung
Pressure-Vol ume Curve
Surface Tension
ses of Regi onal Differences
Airway Closure
stic Propert ies of the Chest
ay Resist ance
Airfl ow through Tubes
Measurement of Airway
Pressures during t he Breathing
Chief Site of Airway Resistance
Factors Det ermining Airway
Resist ance
Dynamic Compression of
Causes of Uneven Ventilation
Tissue Resistance
Work of Breathing
Work Done on the l ung
Total Wor k of Breat hing
Ve sawin Chapter 2 that gasgets to andfromthealveoli by theprocessof ven-
.etion. We now tum to the forces that movethe lungandchest wall, andthe
resistsnces thattheyovercome. Firstwe consider the musclesof respiration,
bothinspiration and expiration. Then we look at the factors determining the
eastic properties of the lungincludingthe tissueelementsandtheair-liquid
surfacetension. Next we examine the mechanism of regionaldifferencesin
entiletion andalso the closure of small airways. Just asthelung is elasticsois
-'e chest wall and we lookat theinteraction between thetwo. Thephysical
principl es of airway resistance are then considered along with its measure-
ment, chief site in the lung, andphysiological factors that affect it. Dynamic
compression of the airways duringa forced expiration is analyzed. Finallythe
work required to movethe lung and chest wall is considered.
Muscles of Respiration

The most important muscle of inspiration is the diaphragm. This consists of a tht
dome-shaped sheet of muscle that is insert ed int o the lower ribs. It is suppli ed
the phrenic nerves from cervical segments 3, 4, and 5. When it cont racts, the a'
domina I cont ents arc forced downward and forward. and the vert ical dimensi
of the chest cavity is increased. In addit ion, the rib margins are lifted and mov
out , causing an increase in the transverse diamet er of the thorax (Figure 1).
In normal tidal breathing, the level of the diaphragm moves about 1em or
hut on forced inspirat ion and expiration, a total excursion of up to 10 cm may
-Cuf. When the diaphragm is paralyzed, it moves up rather than down with in-p
ration because the intrathoracic pressure falls. This is known as parado.\ical mot
ment and can be demonstrated a t fluoroscopy when th e subject sniffs.
The external imercostal muscles connect adjacent ribs and slope downward a
forward (Figure 7-2) . When they contract, the rihs are pulled upward and forwar
causing an increase in both the lateral and anteroposterior diameters of the rh
rax, The lateral dimension increases because of the "bucker-handle" movemen
of the ribs. The intercostal muscles are supplied by intercostal nerves that co
off the spinal cord at the same level. Paralysis of the intercostal muscles alon
does not seriously affect breathing because the diaphragm is so effect ive.
+ 1
. ,
: ...


- - - - .... Passive
Figur e 7-1. On insp ir ati on, t he dome-shaped diaphragm cont racts. the abdomi na
contents are fo rced down and forward, and t he ri b cage is widened. Bot h i ncrease
the volume of t he thorax. On forced expi rat ion, the abdomi nal muscles contract:
and push the dia phr agm up.
Axis of rotation
Figu re 7-2. Wh en the ext ernal intercostal mu scles cont ract. the ribs are pulled up-
ward and forwa rd, and t hey rot ate on an axis j oining the tubercle and head of ri b.
As a result , bot h the lateral and anteroposter ior diameters of the thorax increase.
The internal int ercostals have the opposite action.
The accessory muscles of inspiration includ e the scalene muscles whic h elevat e
the first two ribs, and the srcmornastoids whic h raise the sternum. There is lit tle,
if any, act ivity in these muscles during quiet breathing, but during exercise they
may contract vigorously. Other muscles that play a minor role include the alae
nasi, which cause flaring of th e nostrils, and small muscles in the neck and head.
Expirat ion
Th is is passive during quiet breathing. The lung and chest wall are elast ic and
tend to return to their equilibrium posit ions after being act ively expanded Ju ring
inspirat ion . During exercise and voluntary hyperventi lat ion, expirat ion becomes
act ive. The most important muscles of expirat ion are those of the abdominal wall,
including the rect us abdomi nis, internal and ext ernal oblique muscles, and
transversus abdominis. When these muscles contract, intra-abdominal pressure is
raised, and the diaphragm is pushed upward. These muscles also contract force-
fully Juring coughing, vomiting, and defecation.
The internal intercostalmuscles assist active expiration by pulling the ribs down-
ward and inward (opposite to the action of th e external int ercostal muscles), th us
decreasing the tho racic volume. In addit ion, they st iffen the intercostal spaces to
prevent them from bulging outward during st raining. Experimental studies show
tha t the act ions of the respiratory muscles, especially the intercostals, are more
complicated than th is brief account suggests.
Respi rat ory Muscles
• Inspirat ion is active; expiration is passive during rest
• Diaphragm is the most important muscle of inspiration; it is supplied by
phrenic nerves wh ich originate high in the cervical region
• Other muscles include the int ercostals. abdomina! muscles, and accessory
Elastic Properties of the Lung
Figure 7-3. Measureme nt of t he pr essur e-vo l ume curve of exci sed lung. The lung
is hel d at each pressure for a few seconds while it s vol ume is measured. The curve
is nonl inear and becomes flatter at high expanding pr essur es. Note t hat the infla-
t ion and def lation curves are not the same; thi s is called hyster esis.
- 30 - 20 - 10
Pressure around lung (cmwater)
Volume (I)
Pressure-Volume Curve
Suppose we take an excised animal lung, cannulat e the trachea, and place it in-
side a jar (Figure 7-3). When rhe pressure with in the jar is reduced below atmo-
spheric pressure, th e lung expands and its cha nge in volume can be measured with
a spirometer. The pressure is hel d at each level, as indicated by the points, for a
few seconds to allow the lung to come to rest. In thi s way, the pressure-volume
curve of the lung can be plotted.
In Figure 7-3, the expanding pressure around the lung is generated by a pump,
but in humans it is developed by an increase in volume of the chest cage. The fact
that the intrapleural space between the lung and chest wall is much smaller than
the space between the lung and the bottle in Figure 7 ~ 3 makes no essent ial dif-
ference. The intrapleural space contains only a few millili ters of fluid.
Figure 7-3 shows that the curves whi ch th e lung follows during infl ation and
deflation are different. This behavior is known as!ysteresis. Note th at the lung IS:
volume at any given pressure during deflat ion is larger than during inflati on. Note (i;
also that the lung without any expanding pressure has some air inside it. In fact ,
even if the pressure around the lung is raised above at mospheric pressure, little
further air is lost because small airways close, tr apping gas in (he alveoli (compare
Figure 7-9). This airu.!ay closure occurs at hi gher lung volumes with increasing age
and also in some types of lung disease.
In Figure 7 ~ 3 the pressure inside the airways and alveoli of the lung is the same
as atmospheric pressure, which is zero on the horizontal axis. Thus, this axis also
measures the difference in pressure between the inside and outside of the lung.
This is known as transpulmonary pressure and is numerically equal to the pressure
around the lung when the alveolar pressure is atmospheric. It is also possible to
measure the pressure-volume relationship of the lung shown in Figure 7-3 hy in-
t1ating it with posit ive pressure and leaving the pleural surface exposed to the at-
mosphere. In this case, the horizontal axis could be labeled "airway pressure," and
the values would be positive. The curves would he identical to those shown in
Figure 7-3.
Compl i ance
The slope of the pressure-vo lume curve, or the volume change per uni t pressure
change, is known as the compliance. In the nor mal range (expanding pressure of
about - 5 to - 10 em water) the lung is rernarka hlv distensible or very compliant.
The compliance of.the human lung is about 200 mi · em water-i . However, at
high expandi ng pressures, the lung is stiffer, and its compliance is smaller, as
shown by the flatter slope of the curve.
A reducedcompli ance is caused byan increase of fibrous tissue in the lung (pul -
monary fibrosis). In addit ion, compliance is reduced by alveolar edema \v-hich
prevents the inflati on of some alveoli. Compliance also falls if the lung remains
unventilated for a long period, especia lly if its vol ume is low. This may be partl y
caused by atelec tasis (collapse) of some units, but increases in surface tension also
occur (see below). Compliance is also reduced somewhat if the pulmonary venous
pressure is incr eased and the lung becomes engorged with blood.
An increased compliance occurs in pulmonar y emphysema and in the normal
aging lung. In bot h instances, an alteration in the clastic tissue in the lung is prob-
ably responsible. Increased compliance also occurs dur ing an asthma attack, hut
the reason is uncl ear.
The compliance of lung depends on its size. Clearly, the change in volume per
unit change of pressure will be larger for a human lung than, sayt a mouse lung.
For thi s reason, the compliance per unit volume ofl ung, or specific compliance, is
somet imes measured if we wish to draw concl usions about the intrinsic elastic
propert ies of th e lung tissue.
The pressure surrounding the lung is less than at mospheric in Figure 7;3 (and
in the living chest) because of the elastic recoil of the lung. What is responsible
for the lung's elastic behavior, that is, its tendency to return to its rest ing volume
aner distension ?One factor is the elastic tissue which is visible in histological sec-
tions. Fibers of elasti n and collagen can be seen in the alveolar walls and around
vessels and bronch i. Probably the clastic behavior of the lung has less to do with
simple elongation of these fibers th an it does with their geometr ical arrangement.
An analogy is a nylon stocking which is very distensible because of its knitted
make-up, although the indi vidual nylon fibers arc very difficult to stretch. The
changes in elastic recoil that occur in the lung with age and in emphysema are
presumably caused by cha nges in this clast ic t issue.
Surf ace Tension
Another important factor in the pressure-volume behavior of lung is the surface
tension of the liquid film lining the alveoli. Surface tension is the force (in dynes,
c r example) acting across an imaginary line I -ern long in rhe surface of the liq-
Pressure-Volume Curve of the Lung
• Nonlinear with the lung becoming stiffer at high vol umes
• Shows hysteresis bet ween inflation and defl at ion
• Compliance is t he slope J.V/J.P
• Behavior depends on both structural proteins (collagen, elastin) and surface
uid (Figure 7 ~ 4 A ) . It ari ses because the att rac t ive forces bet ween adja cent
molecules of the liquid are much stronger than those between the liquid and gas,
with the result that the liquid surface area becomes as small as possible. This be-
havior is seen clearly in a soap bubble blown on the end of a tube (Ftgure 7-4B).
The surfaces of the bubble contract as much as they can, forming a sphere (small -
est surface area for a given volume) and generat ing a pressure that can be pre-
dicted from Laplace's law: pressure = (4 X surface tension)/radius. When onl y
one surface is involved in a liquid-lined spherical alveolus, the numerator has the
number 2 rather than 4.
The first evidence that surface tension might contribute to the pressure-
volume behavior of the lung was obta ined by early physiologists when they
showed that lungs inflat ed with saline have a much larger compliance (are easier
to distend) than air-filled lungs (Figure 7-5). Because the saline abolished th e sur-
face tension forces but presumably did not affect the tissue forces of th e lung, this
observation meant that surface tension contributed a large part of the stat ic recoil
force of the lung. Some time later, workers studying edema foam coming from the
lungs of animals exposed to noxious gases not iced that the t iny air bubbles of the
foam were extremely stable. They recogni zed th at thi s indicated a very 10\'L
surface tension, an observation whic h led to the remarkable discovery of pul-
monary surfactant.
1 em
->-, ,+-
, ,
..... t.:

i/ /:/
, ,
~ _ . ~ --J,
? \
Soap bubble
Figure 7-4. A. Surface t ension is th e fo rce (in dynes, f or example) act i ng across an
imaginary line 1 em long in a li quid surface. B. Surface fo rces i n a soap bubble
tend to reduce t he area of the surface and generate a pres sure wit hin t he bubbl e.
C. Because the small er bu bbl e ge nerates a larger pressure, it bl ows up the
larger bubble.
Pressure (em water)
Figure 7-5. Compa rison of press ure-volume curves of air-filled and safine-fllled
lungs (cat) . Open ci rcles, i nf lation; closed circles, def lation. Note that t he saline-
filled lung has a higher compliance and also much less hysteresis than the air -
f i lled l ung.
It is nowknown that some of the cells lining the alveoli secrete a materi al t hat
profoundly lowers the surface tension of the alveolar lining fluid. Surfactant is a
phospholipid, and dipalmitoyl phosphat idylcholine (OPPC) is an important con-
stituent. Alveolar epit he lial cells are of two types. Type I cells have the shape of
a fried egg with long cytoplasmic extensions spreading out thinly over the alveo-
lar walls (Figure 1-1). Type II cells are more compact (Figure 7-6), and electron
microscopy shows lamel lated bodies wit hin them that are extruded into th e alve-
oli and transform into surfactant. Some of me surfactant can be washed out of an-
imallungs by rinsing them with saline.
The phospholipid OPPC is synthesized in the lung from fatt y acids that at e ei-
ther extract ed from the blood or are themselves synt hesized in the lung. Synt he-
sis is fast, and th ere is a rapid turnover of surfact ant. If the blood flow to a region
of lung is abolished as th e result of an embolus, for example , th e surfactant there
may be deplet ed. Surfactant is formed relati vely late in fet al life, and babies born
without adequate amounts develop respiratory distress and may die.
The effects of this materi al on surface tension can be studied with a surface bal-
ance (Figure 7·7) . This consi sts of a tray containi ng saline on which a small
amount of test material is placed. The area of the surface is then alternately ex-
panded and compressed by a movable barrier while rhe surface tension is mea-
sured from the force exerted on a platinum strip. Pure saline gives a surface ten -
sion of about 70 dynes/em, regardless of the area of its surface. Adding detergent
reduces the surface ten sion, but again this is independent of area. Wh en lung
washi ngs are placed on the saline, the curve shown in Figure 7-7B is obtained.
Note th at the surface tension changes greatl y with the surface area and mat ther e
Figure 7-6. Elect ron micrograph of type \I epit hel ial cell (x 10,OOO). Note the lamel-
lated bodi es (LB), large nucl eus, and mi crovilli (arrows). The inset at top right is a
scanni ng elect ron micrograph showing t he surf ace view of a typ e II cell wi t h its
characteristic di st ribution of mi crovi l li (x3400).
is hysteresis (compa re Figure 7 ~ 3 ) . Note also that the surface tension falls to ex,
tremclv low values when the area is small.
How does surfact ant reduce the surface tension so much ? Apparently the
molecules of DPPC are hydrophobic at one end and hydroph ilic at the ot her, and
they align themselves in the surface. When thi s occurs, the ir inter molecular re,
pulsive forces oppose the normal attract ing forces between th e liqui d surface
molecules that are responsible for surface tension . The reduct ion in surface ten,
sion is greater when the film is compressed because the molecules of DPPC are
then crowded closer together and repel each ot her more.
What arc the physiological advantages of surfactant? First , a low surface ten,
sion in the alveoli increases the compliance of the lung and reduces the work
of expanding it with each breath. Next, stability of the alveoli is promoted. TIle
300 million alveoli appear to be inh erentl y unstable beca use areas of atelectasis
(collapse) often form in the presence of disease. This is a comp lex subject , but one
wav of looking at the lung is to regard it as a collect ion of millions of tiny bubbles
(alt hough th is is clear ly an oversimplificat ion) . In such an arrangement , there is
'I ?if
I Water 11
11 Detergent i
a 25 50 75
Surfacetension (dynes/ em)
Figure 7-7. A. Surface balance. The ar ea of the surf ace is alter ed, and the surface
tension is measured from the f or ce exerted on a pl at inum strip dip ped into the
surf ace. B. Plots of surface t ensio n and area obtai ned with a surface balance. Note
t hat lu ng wash ing s show a change in surf ace tens ion wit h area and t hat the min-
imal tension is very smal l. The axes are chosen t o all ow a comparison wit h the
pressure-volu me cur ve of the lung (Figures and 7-5).
a tendency for small bubbles to collapse and blow up large ones. Figure 7-4C
shows th at the pressure generated by the surface forces in a bubble is inversely
proport ional to its radius, with the result that if the surface tensions arc the same,
the pressure inside a small bubble exceeds that in a large bubble. However, Figure
7 7 shows that when lung washings are present, a small surface area is associated
with a small surface tension. Thus, the tendency for small alveoli to empty into
large alveoli is apparentl y reduced. ">,
; A thi rd role of surfactant is to help to keep th e alveoli dry. Just as th e sur-
face ten sion forces tend to collapse alveoli, th ey also ten d fluid into the
alveolar spaces from the capillaries. In effect , th e surface tension of th e curved
alveolar surface reduces th e hydrostat ic pressure in thc t issue outside th e capil-
lari es. By reducing th ese surface forces, surfactant prevents the tr an sudation of
What are the consequences of loss of surfactant? On the basis of its func t ions
discussed above , we would expect these to be st iff lungs (low compliance), areas
of atelectasis, and alveoli filled wit h transudat e. Indeed, these are the pat hophys-
iological feat ures of the "infant respiratory di stress syndrome,' and thi s disease is
caused by an absence of th is cruci al material. It is now possible to treat these tn-
fants by instilling synthes ized surfactant int o the lung.
Pulmonary Surfactant
• Reduces the surface tension of the alveolar lining layer
• Produced by type II alveolar epithelial cells
• Contains dipalmitoyl phosphatidylcholine
• Absence results in reduced lung compliance, alveolar atelectasis, and ten-
dency to pulmonary edema
There is another mechanism that apparently cont ributes to the stability of the
alveoli in the lung. Figures 1-2, 1-7, and 4-3 remind us that all the alveoli (excep t
those immediately adjacent to the pleural surface) are surrounded by other alve-
oli and are therefore supported by each other. In a structure such as this with
many connect ing links, any tendency for one group of units to reduce or increase
its volume relat ive [0 the rest of the structure is opposed. For example, if a group
of alveoli has a tendency to collapse, large expanding forces will be developed on
them because the surroundi ng parenchyma is expanded.
This support offered to lung uni ts by those surroundi ng them is ter med "inter-
dependence." The same factors explain the development of low pressures around
large blood vessels and airways as the lung expands (Figure 4-2) .
Cause of Regional Differences in Ventilat ion
\Y,fe saw in Figure 2-7 that the lower regions of the lung ventilate more than do
the upper zones, and this is a convenient place to discuss the cause of these topo-
graphical differences. It has been shown that the intrapleural pressure is less neg-
at ive at the bottom rhan th e top of the lung (Figure 7-8). The reason for thi s is
the weight of the lung. Anything that is supported requires a larger pressure be-
low it than above it to balance the downward-acti ng weight forces, and the lung,
which is partl y supported by the rib cage and diaphragm, is no exception. Thus,
th e pressure near the base is higher (less negative) than at the apex.
J ~
A •
50% ~
+10 o - 10 - 20
- 30
Intrapleural pressure (ern H20)
Figure 7-8. Explanation of the regional di fferences of ve nt i lat ion down t he lung.
Becau se of t he weight of t he lung, t he i ntr apl eural pressure is less negat ive at t he
base t han at the apex. As a consequence, t he basal lung is relativel y compressed
in its rest in g st ate but exp ands mor e on in spir at ion t han t he apex.
Figure 7~ 8 shows the way in which the volume of a porti on of lung (for example,
a lobe) expands as th e pressure around it is decreased (compare Figure 7-1) . The
pressure inside th e lung is the same as atmospheric pressure. Not e that the lung is
easier to inflate at low volumes than at high volumes, where it becomes stiffer. Be-
cause the expanding pressure at the base of th e lung is small, this region hasa small
resting volume. However, because it is situated on a stee p part of the pressure-
volume curve, it expands well on inspirat ion. By contrast, the apex of the lung has
a large expanding pressure, a big resting volume, and small change in volume in
inspirat ion.*
Now when we talk of regional differenc es in ventilation , we mean the change
in volume per unit resti ng volume. It is clear from Figure 7-8 tha t the base of the
lung has bot h a larger change in volume and smaller rest ing volume than the
apex. Thus, its vent ilat ion is greater. Not e the paradox that , although the base of
the lung is relati vel y poorly expanded compared with the ape x, it is better vent i-
lated. The same explan ati on can begiven for thc large ventilation of dependent
lung in both the supine and lateral positions.
A remarkable change in the distribution of ventilation occurs at low lung vol-
umes. Figure 7-9 is similar to Figure 7· 8 except tha t it represents the situa t ion at
-4 em H
pressure (RV)
+3.5 em H
50% ~
+10 o - 10 -20
- 30
Intrapleural pressure (em H
0 )
Figure 7-9. Situation at ve ry low lung volumes. Now i nt rapleural pressur es ar e
less negati ve, and t he pr essure at t he base actu all y exceeds ai rway (at mospheric)
pressure. As a consequence, air way cl osure occurs in t his reg ion, and no gas en-
te rs wi t h small i ns pirations.
* This explana tion is an over simplificat ion because the pressure-volume behavi or of a por-
tion of a structure like the lung may not be identical to that of th e whole organ.
residual volume (that is, after a full expiration , see Figure 2-2). Now the in-
trapleural pressures arc less negat ive beca use the lung is not so well expanded and
the elastic recoil forces are smaller. However, the differences bet ween apex and
base are st ill present because of the weight of the lung. Not e th at the intrapleural
pressure at the base now actually exceeds airway (at mospheric) pressure. Under
these condit ions, the lung at the base is not being expanded but compressed, and
vent ilation is impossible until the local intrapleural pressure falls below atmo-
spheric pressure. By contrast, the apex of the lung is on a favorable part of the
pressure-volume curve and vent ilates well. Thus, the normal distr ibut ion of ven-
tilat ion is inverted, the upper regions vent ilat ing better than th e lower zones.
Airway Closure
The compressed region of lung at the base does not have all its gas squeezed out.
In practice, small airways, probably in the region of respiratory bronchioles (Fig-
ure 1 close first , thus trapping gas in the distal alveoli. This airway closure oc-
curs only at very low lung volumes in young normal subjects. However, in elderly
apparentl y normal people, airway closure in the lowermost regions of the lung oc -
curs at higher volumes and may be present at funct iona l residual capacity (Figure
The reason for this is that the aging lung loses some of its elastic recoil, and
int rapleural pressures therefore become less negati ve, thus approaching the situ-
at ion shown in Figure 7 In these circumstances, dependent (rhar is, lowermost )
regions of the lung may be only intermi ttently vent ilated, and this leads to de-
fect ive gas exchange (Chapter 5). A similar situat ion frequently develops in pa-
tien ts with some types of chronic lung disease.
Elastic Properties of the Chest Wall
Just as the lung is elastic, so is the thoracic cage. This can be illustrated byputt ing
air into the int rapleural space (pneumot horax) . Figure shows that the nor -
mal pressure outside the lung is subatmospheric just as it is in the jar of Figure
7 When air is introduced into the int rapleural space, raising the pressure to at -
mospheric. the lung collapses inward, and the chest wall springs outward. This
P= Q
P = - 5
Pneu mothorax
Figure 7-10. The tendency of th e lung t o recoil to its defl at ed volume is balanc ed
by th e t endency of the chest cage to bow out . As a resul t, the i nt rapleural pressure
is subatmospheric . Pneumot horax allows t he lun g to coll apse and t he t horax to
spri ng out .
• ,



' '"
• sr
J ?;
' '"
I §':
' 'I- I

" :

...., ,


• •
• •
• •
respiratory /
___ .L:
• 50
--..... - - - - - ---- -


• • ,

• •




I :>

. ..,


Residual I 25
I -.cvolume I
-I _ _ __ _ _ _ _ _ _
' _ ______ _ _ .1_ _
--------- - --
___ __l- -

- 20 -1 0 0 +10 +20 +30
Airway pressure (em water)
Figure 7-11. Rel axat ion pressure-volume curve of the lung and chest wal l. The
subj ect inspir es (or expi res) to a cert ain vo lume f rom t he spi rometer, t he tap is
cl osed, and th e subject t hen relaxes his respiratory muscl es. The curve f or lung +
chest wall can be expl ai ned by the addit ion of t he in dividual lun g and chest wall
shows that under equilibrium condi t ions, the chest wall is pulled inward while th e
lung is pulled Durward, the rwo pulls balanc ing each other.
These interactions can be seen more cl early if we plot a pressure-volume curve
for the lung and chest wall (Figure 7-11) . For this, the subject inspires or expires
from a spirometer and then relaxes th e respiratory muscles while the airway pres,
sure is measured ("rel axation pr essure"). Incidentally, th is is difficult for an urt-
rrained subject. Figure 7-11 shows that at functiona l residual capacity (FRC) , the
relaxat ion pressure of the lung and chest wall is atmospheric. Indeed, FRC is the
equilibrium volume when the clastic recoil of the lung is balanced bythe norma]
rendencvfqr th echest wall [Q spring out. At volumes above thi s, the pressure is
posit ive, and at smaller volumes, the pressure is subatmospheric.
Figure 7-11 also shows the curve for the lung alone. This is similar to that
shown in Figure 7,3 , except that for clarity no hysteresis is indicat ed and the pres-
sures are positive instead of negati ve. They arc the pressures that would be found
from the experiment of Figure 7 if, after the lung had reached a certain volume,
the line to the spiromete r were clamped, the jar opened to the at mosphere (so
that the lung relaxed against the closed airway), and the airway pressure mea-
sured. Note tha t at zero pressure the lung is at its minimal volume, whi ch is be-
low residual volume (RV) .
The third curve is for the chest wall only. We can imagine this being measured
on a subject with a normal chest wall and no lung! Note that at FRe the relax-
ati on pressure is negat ive. In other words, at thi s volume the chest cage is tend-
ing to spring out. It is not unt il the volume is increased to about 75% of the vital
capacity that the relaxat ion pressure is atmospheric, th at is, that the chest wall
has found its equilibrium position. At everyvolume, the relaxati on pressure of the
lung plus chesr wall is the sumof the pressures forthe lung and the chest wall mea-
sured separately. Because the pressure (at a given volume) is inve rsely propor -
tional to compliance, thi s implies that the total compliance of the lung and chest
wall is the sum of the reciprocals of the lung and chest wall compliances measured
separately, or IIC
Relaxation Pressure-Volume Curve
• Elastic properties of both the lung and chest wall determine thei r combined
• At FRC, the inward pull of the lung is balanced by the outwa rd spring of the
chest wall
• Lung retracts at all volumes above minimal volume
• Chest wall tends to expand at volumes up to about 75% of vital capacity
Airway Resistance
Airflow Through Tubes
If air flows th rough a tube (Figure 7 ~ 1 2 ) , a difference of pressure exists between
the ends. The pressure difference depends on the rate and pattern of flo"..·. At low
flow rates, rhe stream lines are parallel to the sides of the rube (A). This is known
as laminar £10\\-' . As the flow rate is increased, unsteadiness deve lops. especially at
branches. Here, separat ion of the stream lines from the wall may occur with the
formati on of local eddies (8). Ar srill hi gher flow rates, complete disorganizati on
of th e stream lines is seen; thi s is turbulence (C).
The pressure-flow characteristics for laminar flow were first described by the
French physician Poiseuille. In straight circular rubes, the vol ume flow rate is
given by
. Pm
V =--
where P is th e dr iving pressure ( ~ P in Figure 7-12A), r radius, n viscosity, and I
length. It can be seen that driving pressure is proport ional to flowrate, or P = KV.
Laminar Turbulent
Tr ansit ional
Figure 7-12. Patterns of airflow i n tubes. In A, the flow is lami nar; in S, tra nsi tional
wi t h eddy fo rma t ion at branches; and i n C, turbulent. Resistance is (Pl - P2)1f low.
Because flow resistance R is driving pressure divided by flow (compare p. 32), we
R =
Note the critical importance of tube radius; if the radius is halved, the resistance in-
creases doubling the length only doubles resistance. Note also
that the gas, but ,n...9-.l1ts density, affects the pressure-flow
Another feature of lami nar flow when it is fully devel oped is that the gas in the
center of the tube moves twice as fast as the average velocity. Thus, a spike of
rapidly moving gas travels down the axis of the tube (Figure 7-12A) . This chang-
ing velocity across the diameter of the tube is known as the velocit), profile.
Turbulent flcxv has different properti es. Here pressure is not proport ional to
flow rate but , appro ximately, to its square: P = KV
• In addit ion, the viscosity of
the gas becomes relat tvelv ununpcr tantbut an increase in gas density increases___
the pressure drop for a given flow. Turbulent flow does not have the high axial---\
flow velocity that is characteristic of laminar flow.
Whether flow will be laminar or turbulent depends to a large extent on the
Reynolds number, Re. This is given by
Re= - .-
where d is density, v average velocity, r radius, and n viscosity. Because densit y
and veloc ity are in the nume rator, and viscosity is in th e denominator, the ex-
pression gives the rati o of inertial to viscous force s. In stra ight, smooth t ubes, tur-
bulence is probable when the Reynolds number exceeds 2000. The expression
shows that turbulence is most likel y to occur when the velocity of flow is hi gh and
the rube diameter is large (for a given velocity). Not e also that a low-density gas
like helium tends to produce less turbulence.
In such a complicated system of tubes as the bronchial tree with its many
branches, changes in caliber, and irregular wall surfaces, the application of the
above principles is difficult. In practice, for laminar flow to occur, the entrance
conditions of t he tube are critical. If eddy format ion occurs upstream at a branch
point , thi s disturbance is carried downstream some distance before it disappears.
Thus, in a rapidly branching system like the lung, fully developed laminar flow
(Figure 7-12A ) probably onlyoccurs in the verysmall airways where the Reynolds
numbers are very low (approxi mate ly 1 in termina l bronchioles). In most of the
bronchial tree, flow is transitional (B), while true turbulence may occur in the
trachea, especiall y on exercise when flow vel ocities are high. In general, driving
pressure is determined by both the flow rate and its square: P =K
\; + K, \;' .
Laminar and Turbulent Flow
• In lami nar fl ow, resistance is determined by the fourt h power of t he radius
• In lami nar flow, the velocity profile shows a central spi ke of fast gas
• Turbulent flow is most lik.ely to occur at high Reynolds number s, that is
wh en inertial forces dominate over viscou s forces
Measurement of Airway Resistance
Airway resistance is the pressure difference between the alveoli and the mouth di-
vided by a flow rate (Figure 7-12). Mouth pressure is easily measured with a
manometer. Alveolar pressure can be deduced from measurements made in a
bodv plethysmograph. More informat ion on thi s technique is given on p. 152.
Pressures During the Breathing Cycle
Suppose we measure th e pressures in t he intrapleural and alveolar spaces during
normal breathing." Figure 7 ~ 1 J sho ws that before inspirat ion begins, the in-
trapl eural pressure is - 5 cm water because of the elast ic recoil of the lung (corn-
pare Figures 7~ 3 and 7~ 10). Alveolar pressure is zero (atmosphe ric) because with
no airflow, there is no pressure dro p along the airways. However , for inspiratory
flow to occur, the alveol ar pressure falls, thus est ablish ing the dri vi ng pressure
(Figure 7- 12) . Indeed, the ext ent of the fall depends on the flow rate and the
resistance of the airways. In normal subjects, the change in alveolar pressure is
only I -cm wat er or so, but in pati en ts with airway obstruct ion, it may be many
t imes that.
Intrapleural pressure falls during inspirat ion for two reasons. First , as the lung
expands, its elast ic recoil increases (Figure 7 ~ 3 ) . This alone would cause the in-
Figure 7-13. Pressures du ring the breathi ng cycle . If there were no _ainYay resis-
tance, alveolar pressure would remain at zero, and i ntrapleural pressure would
follow th e brokentine ABC. wh ich is det er mi n ed by t he elastic recoi l of the lung.
Airway (and t issue) resi st ance cont ri butes the hatched portion of i nt rapleural
pressur e (see t ext ). - -
trapleural pressure to move along the broken line ABC. In addition , however, the
pressure drop along the airway is associated with a further fall in intrapleural pres,
sure,' represenred by the hatched area, so that the actual path is AB' C. Thus, the
vertica l distance between lines ABC and AB'e reflects the alveolar pressure at
any instant. As an equat ion of pressures, (mouth - intrapleural) = (mouth -
alveolar} + (alveolar - intrapleural) .
On expirat ion, similar changes occur. Now int rapleural pressure is less nega-
tive than it would be in the absence of airway resistance because alveolar pressure
is positive. Indeed, with a forced expirat ion, intrapl eural pressure goes above zero.
Note that the shape of the alveolar pressure tracing is similar to that of flow.
Indeed, they would be ident ical if the airway resistance remained constan t during
the cycle. Also, the intrapleural pressure curve ABC would have the same shape
as the volume tracing if the lung compli ance remained constant.
.1: There is also a contri bution made by t issue resistance, which is considered later in this
Chief Site of Airway Resistance
As the airways penetrat e toward the periphe ry of the lung, they become more
numerous but much narrower (see Figures 1 ~ 3 and 1 ~ 5 ) . Based on Poiseuillc' s
equation with its (radius)" term, it would be nat ural to think that the major part
of the resistanc e lies in the very narrow airways. Indeed, thi s was thought to be
t he case for man y years. However , it has now been shown bydirect measure ments
of the pressure drop along the bronchial tree that the major site of resistance is
the medium-sized bronchi and that the very small bronchi oles contr ibute rela-
t ivel y li ttl e resistance. Figure 7· 14 shows that most of th e pressure drop occurs in
the airways up to the seventh gene rat ion. Less than 20% can be attributed to ai r-
ways less th an 2 mm in diameter (about generat ion 8). The reason for this appar-
ent paradox is the prod igious number of small airways.
The fact that the peripheral airways contribute so lit tle resista nce is import ant
'14..<- in the de tec tion of early airway disease. Because they consti tute a "silent zone ," it
-y---:. is probable that considerable small airway disease can be present before the usual
measurements of airway resistance can detect an abnormali ty. This issue is con-
sidered in more det ail in Chapter 10.
J .08 e-

~ ,04
Segmental a: Terminal
1 1
•• II' ••
0 5 10 15 20
Airway generation
Figure 7-14. Locati on of t he chief sit e of airway resistance. Not e t hat the interme-
di ate-sized bron chi cont ri bute most of t he resi stan ce and t hat relati vel y li ttl e is lo-
cated i n t he very small airways.
3 3
o 2 4
Lung volume (I)
6 8
Figure 7-15. Variation of airway resi st ance (AWR) with lung vol ume. If th e reci p-
roca l of ai rway resi stance (conduct ance) is plotted, t he graph is a st raig ht li ne.
Fact ors Determining Airway Resistance
Lung volume has an important effect on airway resistance. Like the extra-alveolar
blood vessels ( Figure 4-2), th e bronchi are supported by th e radial tracti on of the
surrounding lung tissue, and th eir caliber is increased as the lung expands (com-
pare Figure 4,6). Figure 7-15 shows tha t as lung volume is reduced , airway resis-
lance rises rapi dly. If th e reci procal of resistance {conductance} is plotted against
lung volume. an approx ima tel y linear rel at ionship is obtained.
At very 10\\·- lung volumes, the small airways may close comp let ely, especially
at the bottom of the lung, where the lung is less well expanded (Figure 7-9) .
Patients who have increased airway resistance often breat he at hi gh lung vol-
urnes; thi s helps to reduce their airway resistance.
Contract ion of bronchial smooth muscle narrows the air ways and increases air,
way resistance. This may occur reflexly through the st imulat ion of receptors in
the trachea and large bronchi by irrit ants such as cigaret te smoke. Motor inner'
vation is by the vagus nerve. The tone of the smooth muscle is under the control
of the autonomi c nervous system. St imulat ion of adrenergic recept ors causes
bronchod tlaration as do epinephrine and isoproterenol.
J1 ,Adrenergic receptors are of two types: ~ l receptors occur princi pally in the
heart, while 132receptors relax smooth muscle in the bronchi , blood vessels, and
uterus. Sel ect ive 13 2, adrenergic agonisrs are now extensively used in the treat ,
ments of asthma.
Parasympat hetic act ivity causes bronchoconstr icrion , as does acetylcholine . A
fall of r eozin alveolar gas causes an increase in airway resistance, apparently as a
result of a di rect act ion on bronch iolar smooth muscle. The injecti on of his,
Airway Resistance
• Highest in t he medium-sized bronchi; low in very small airways
• Decreases as lung volume rises because the airways are then pulled open
• Bronchial smooth muscle is controlled by the autonomic nervous system;
stimulation of J!-adrenergic receptors causes bronchodilatation
• Breathing a dense gas as in divi ng increases resistance
tamine into the pulmonaryartery causes constriction of smooth muscle located in
the alveolar ducts.
TIl e density and viscosityof the inspired gas affect the resistance offered to flow.
The resistance is increased duri ng a deep dive because the increased pressure
raises gas densit y, but it is reduced when a helium-Oj mixt ure is breathed. The
fact that changes in density rather than viscosity have such an influence on re-
sistance is evidence that flow is not purely laminar in the medi um-sued airways,
where the main site of resistance lies (Figure 7-14).
( Dynamic Compression of Airways' .
Suppose a subject inspires to total lung capacity and then exhales as hard as pos-
sible to residual volume. \X' e can record a curve like A in Figure 7 16,
which shows that flow rises very rapidly to a hi gh value but then declines over
most of expirat ion. A remarkable feat ure of this flow-volume envelope is that it
is virtually impossible to penetrate it. For example, no matter whether we start ex-
haling slowly and then accelerate. as in B. or make a less forceful expira tion, as in
C. the descending port ion of the flow-volume curve takes virtually the same pat h.
Figure 7-16. Flow-volume curves. In A, a maximal inspirat ion was f ollowed by a
fo rced expir ation. In 8, expirat ion was i nit iall y slow and t hen forced. In C, expi ra-
to ry effort was submaximal. l n all th ree, t he descending porti ons of the curves are
al most superi mposed.
flow (ilsee)
flow (ilsee)
High lung volume
Mid volume
Low volume
5 10 15 20 25
Intrapleural pressure
(em H
Figure 7-17. lsovolume pr essur e-flow cur ves drawn for three lung vo lumes. Each
of t hese was obtai ned f ro m a series of forced expir at ions and i nspi rat ions (see
text) . Note t hat at t he high lung volume, a rise i n intrapleural pressu re (obt ai ned
by i ncreasi ng expi rato ry effort) results in a gr eat er expir at ory f low. However , at
mi d and low volumes, fl ow becomes i ndependent of effort aft er a cer ta in in-
t raple ural pressure has been exceeded.
Thus, something powerful is limiting expiratory flow, and over most of the lung
volume, flow rate is independent of effort .
We can get more information about this curious stat e of affairs by plotting the
dat a in another way, as shown in Figure 7-17. For thi s, the subject takes a series
of maximal inspirat ions (or expirations) and then exhales (or inhales) fully with
varying degrees of effort. If the flow rates and intr apleural pressures are plotted at
the same lung volume for each expirat ion and inspirat ion, so-called isovolume
curves can be obtained. It can be seen that at high lung volumes, the
expiratory flowrat e cont inues to incr ease with effort, as might be expected. How-
ever, at mid or low volumes, the flow rat e reaches a plat eau and cannot be in-
creased with furt her increase in intrapl eural pressure. Under these conditions,
flow is therefore effort indet)endent.
The reason for this remarkable behavior is compression oi the airways by in-
t rathoracic pressure. Figure shows schematically the forces act ing across an
airway within the lung. The pressure out side the airway is shown as int rapleural,
although this is an oversimplification . In A, before inspiration has begun, airway
pressure is everywhere zero (no flow), and because intrapleural pressure is - 5 ern
water, there is a pressure of 5 cm water holding the airway open. As inspirat ion
A. Preinspi rati on
- 8
o 0
C. End-inspiration
B. During inspi ration
D. Forced expiration
Figure 7-18. Scheme showi ng why ai rways are compressed during forced expi-
rat ion. Not e th at th e pressure difference across t he airway is holdi ng it open, ex-
cept dur i ng a f or ced expi rat ion. See text f or detail s.
starts ( B), bot h intrapleural and alveolar pressure fan by 2 ern wat er (same lung
volume as A and tissue resistance is neglected), and flow begins. Because of the
pressure drop along the airway, the pressure inside is - 1 em water, and there is a
pressure of 6 ern water holding the airway open. At end-inspiration (C ), again
flow is zero, an d there is an airway tran smural pressure of 8 em water.
Finally, at the onset of forced expi rat ion (D), both int rapleural pressure and
alveolar pressure increase by 38 em water (same lung volume as C ). Because of
the pressure drop along the airway as flow begins, there is now a pressure of 11
em water, tending to close the airway. Airway compression occurs, and the
downstream pressure lirrunng flow becomes the pressure outside the airway, or
intrapleural pressure. Thus, the effect ive driving pressure becomes alveolar mi-
nus intrapleural pressure. This is the same Sta rling resistor mechani sm that lim-
its the blood flow in zone 2 of the lung, whe re venous pressure becomes un im-
portant just as mout h pressure does here (Figures 4 ~ 8 and 4 ~ 9 ) . Note that if
intrapleural pressure is raised further by incr eased muscular effort in an attempt
to expel gas, the effective dri ving pressure is una ltered. Thus, flow is indepen-
dent of effort .
Maximal flow decreases wit h lung volume (Figure 7-16) because the differ-
ence between alveolar and imrapleural pressure dec reases and the airways be-
come narrower. Note also that flow is inde pendent of the resistance of the air,
ways downstream of the point of collapse, called the equal pressure point. As
exp irat ion progresses, the equal pressure point moves distally, deeper into the
lung. This occurs because the resistance of the airways rises as lung volume falls,
Dynamic Compression of Airways
• Limits air flow in normal subjects during a forced expiration
• May occur in diseased lungs at relatively low expiratory flow rates thus re-
ducing exercise ability
• During dynamic compression flow is determi ned by alveolar pressur e minus
pleural pressure (not mouth pressure)
• Is exaggerated in some lung diseases by reduced lung elast ic recoil and
loss of radial traction on airways
and therefore the pressure wit hi n the airways falls mor e rapidly with di stance
from the alveoli .
Several factors exaggerate this flow-limi ting mechanism. One is any inc rease
in resistance of the peripheral airways because that magnifies the pressure drop
along th em and thus dec reases the intrabronchial pressure during expiration (19
cm wat er in D). Another is a low lung vol ume because that red uces the driving'--
pressure (alveolar-intrapleural) . This dr ivi ng pressure is also reduced if recoil (
pressure is reduced, as in emphysema. Also in th is disease, radial tr act ion on the
airways is reduced and they are compressed more readily. Indeed, while this type \
of flow limitat ion is only seen during forced expirat ion in normal subj ects, it may(
occur duri ng th e expirations of normal breathing in pati ents with seve re lung
disease. -----
In th e pulmonary function labora tory, the flow rat e during a maximal expi ra-
tion is often determined from the forcedexpirator)' volume or FEY1.0 which is th e
volume of gas that can be exhaled in 1 second after a maximal inspirati on. An-
othe r popular measurement is the forced expiratory flowor FEF
'5_7'5'){>which is the
average flow rate measured over the middle half (by volume) of the expirat ion.
More informat ion about these test s can be found in Chapter 10.
Causes of Uneven Ventilation
The cause of the regional differences in vent ilat ion in the lung was discussed on
p. 103. Apart from these topographical differences, there is some additional in-
equality of venti lat ion at an y given vertical level in the normal lung, and this is
exaggerat ed in many di seases.
One mechani sm of uneven vent ilat ion is shown in Figure 7~ 19. If we rega rd
a lung unit (Figure 2 ~ 1) as an elastic chamber connected to the at mosphe re by
a rube , the amount of ventilation depends on the compli ance of the chamber
and the resistance of the t ube. In Figure 7 ~ 1 9 , uni t A has a normal distensibil-
ity and airway resistance. It can be seen that its volume change on insp irat ion
is large and rapid so that it is comp lete before expiratio n for the whole lung be-
gins (broken line) . By contras t , unit B has a low compliance, and its change in
volu me is rapid but small. Finally, uni t C has a large airway resistance so that
inspiration is slow and not complete before the lung has begun to exhale . Note
that the shorter the time ava ilable for inspiration (fast breathing rate ), the
smaller the inspired volume. Such a un it is said to have a long time constant, the
-----------l ----' l
Time -...
Figure 7-19. Eff ects of decreased compliance (8) and increased ai rway resistance
(Cl an vent ilat ion of lung unit s compared wit h norm al (A). In bot h insta nces, the i n-
spired vol ume is abnormally low.
value of which is given by the product of the compliance and resistance. Thus.
inequality of ventilat ion can result from alterations in eit her local diste nsibility
or airway resistance, and the pattern of inequalit y will depend on t he frequency
of breathing.
Anoth er possibl e mechanism of uneven vent ilat ion is incompl ete diffusion
with in th e airways of rhe respiratory zone (Figure 1 ~ 4 ) . We saw in Chapter 1 tha t
the dominant mechanism of vent ilat ion of the lung beyond the terminal bron-
chi oles is diffusion. Normally this occurs so rapidly th at differences in gas con-
centration in the acinus are virt ually abolished wit hin a fraction of a second.
However, if there is dilat ion of the airways in the region of the respirato ry bron-
chioles, as in some diseases, the distance to be covered by diffusion may be enor-
mously increased. In these circumstances, inspired gas is not distr ibuted uniformly
within the respiratory zone because of uneven ventilat ion along the lung units.
Tissue Resistance
When the lung and chest wall are moved, some pressure is required to overcome
the viscous forces within the t issues as t hey slide over each other. Thus, part of
the hatched portion of Figure 7- 13 should be attri buted to these t issue forces.
HoweverI this tissue resistance is only about 20% of the total (t issue + airway)
resistance in young normal subjects, although it may increase in some diseases.
This total resistance is sometimes called pulmonaryresistance to distinguish it from
airway resistance.
Work of Breathing
\Vork is required to move the lung and chest wall. In this context , it is most con-
ven ient to measur e work as pressure X volume.
Work Done on the Lung
This can be illustrated on a pressure-volume curve (Figure 7 ~ 2 0 ) . Dur ing inspira-
t ion, the intrapleural pressure follows the curve ABC, and the work done on the
lung is given by the area OABCDO. Of this, the trapezoid OAECDO represents the
work required to overcome the elastic forces, and the hat ched area ABCEA rep-
resents the work overcoming viscous (airway and tissue) resistance (compare Fig-
ure 7-13). The hi gher the airway resistance or the inspiratory flow rate, the more
negative (rightward) would be the intrapleural pressure excursion between A and
C and the larger the area.
On expirat ion, the area AECFA is work required to overcome airway ( + ti s,
sue) resistance. Nor mally, thi s falls withi n the t rapezoid OAECDO, and thus this
work can be accomplished by the energy stor ed in the expanded elastic structures
and rele ased duri ng a passive' expiration. The difference between the areas
AECFA and OAECDO represents the work dissipated as hear.
The higher the breathing rate, the faster the flow rates and the larger the vis-
cous work area ABCEA. On the other hand, the larger the t idal volume, the
larger the elast ic work area OAECDO. It is of interest that patient s who have a re-
duced complian ce (st iff lungs) tend to take small rapid breaths, while pat ients
with severe airway obst ruction somet imes breathe slowly. These pattern s tend to
reduce the work done on the lungs.
1. 0
~ 0.5
'" <D
o -5 - 10
Intrapleural pressure (cm H
Figure 7-20. Pressure-volume curv e of t he l ung showing t he inspi ratory work
do ne overco ming elastic f or ces (area OAECDO) and viscous forces (hatched area
Total Work of Breathing
The tot al work done moving the lung and chest wall is difficult to measure, al-
though estimates have been obtained byartificially ventilating paralyzed pati ents
(or "completel y relaxed" volunteers) in an iron lung type of ventilator. Alrerna-
rlvelv, the total work can he calculated by measuring the O
cos t of breat hing and
assuming a figure for the efficienc y as given by
Useful work
Efficiency % = X 100
T ot al energy expended (or 0, cost)
The effic iency i s bel ieved to be about 5 to 10%.
The O
cost of quiet breathing is extremely small, being less than 5% of the
total resting O
consumption. With voluntary hyperventilation it is possible to
increase this to 30%. In patient s with obstructive lung disease, the O
cost of
breathing may limit their exe rcise ability.
For each question, choose the one best answer.
1. All of the following statement s are true about contracti on of t he diaphragm
A. The nerves that are responsible originate high in the neck.
B. It fl att ens the diaphragm.
C. It reduces the lateral distance between the lower rib margins.
D. It causes the anterior abdominal wall to move out.
E. It increases lungvolume.
2. Which of the following statements about the pressure-volume behavior of
the lung is FALSE?
A. Compliance increases with age.
B. Filling an animal lung with saline increases compliance.
C. Removing a lobe reduces total pulmonary compliance.
D. Absence of surfactant reduces compliance.
E. In the upright lung at FRC, for a given change in intrapleural pressure,
the alveoli near the base of the lung expand less than those near the apex.
3. Two bubbles have the same surface tension but bubble X has 3 times the
diameter of bubble Y. The ratio of the pressure in bubble X to that in bubble
V is:
A. 0.3 : 1
B. 0.9 : 1
C. 1 : 1
D. 3 : 1
E. 9 : 1
4. Pulmonary surfactant is produced by:
A. Alveolar macrophages.
B. Goblet cells.
C. Leukocytes.
D. Type I alveolar cells.
E. Type II alveolar cells.
5. The basal regions of the upright human lung are normally bette r ventilated
than the upper regions because:
A. Airway resistance to the upper regions is higher than to the lower
B. There is less surfactant in the upper regions.
C. The blood flow to the lower regions is higher.
O. The lower regions have a small resting volume and a relatively large
increase in volume.
E. The Pco, of the lower regions is relatively high.
6. Which of t he following st atement s is FALSE? Pulmonary surfactant:
A. Reduces the surface tension of the alveolar lining liquid.
B. Is secreted by type II alveolar epithelial cells.
C. Contains dipalmitoyl phosphatidvlcholine .
D. Increases the work required to expand the lung.
E. Helps t o prevent transudati on of fluid f rom the capillaries into the
alveolar spaces.
7. All of the followi ng statements about normal expiration during resting condi-
t ions are true EXCEPT:
A. Expiration is generated by the elastic forces.
B. Alveolar pressure is greater than atmospheric pressure.
C. Intrapleural pressure gradually falls (becomes more negative) during the
D. Flow velocity of the gas (in em . sec") in the large airways exceeds that
in the terminal bronchioles.
E. Diaphragm moves headward as expiration proceeds.
8. An anesthetized patient with paralyzed respiratory muscles and normal lungs
is ventilated by positive pressure. If the anesthesiologist increases the lung
volume 2 liters above FRC and holds the lung at that volume for 5 seconds.
the most likely combinat ion of pressures (in cmH, OI is likely to be:
Mouth Alveolar Int rapleural
A 0 0 - 5
B. 0 +10 -5
C. +10 +10 -10
D. +10 +10 0
E. +10 0 - 10
9. Wh en a normal subject develops a spontaneous pneumothorax of his right
lung all of the following occur EXCEPT:
A Right lung collapses.
B. Chest wall on the right becomes smaller.
C. Diaphragm moves down .
D. Mediast inum may move to the left .
E. Blood flow to the right lung is reduced.
10. According to Poiseuille's Law reducing the radius of an airway to 1/3 will
increase its resistance how many fold?
A 1/3
B. 3
D. 27
E. 81
11. Concerning airfl ow in t he lung:
A. Flow is rnore likely to be turbulent in srnall airways t han in t he t rachea.
B. The lower t he viscosity, the less likely is turbul ence t o occur.
C. In pure laminar flow, halving the radius of t he airway increases its
resistance 8-fold.
D. For inspiration to occur, mouth pressure must be less than alveolar
E. Airway resistance increases during SCUBA diving.
12. The most important factor limitingflow rate duringmost of a forced expira-
tion from total lungcapacity is:
A. Rate of contraction of expiratory muscles.
B. Action of diaphragrn.
C. Constriction of bronchial smooth muscle.
D. Elast icity of chest wall.
E. Compression of airways.
13. All of the followi ng fact ors increase t he resist ance of t he airways EXCEPT:
A. Reduci ng lung vol urne below FRC.
B. Increased sympathetic stimul ation of airway smooth muscle.
C. Divi ng t o a great depth.
D. Inhal ingcigarette smoke.
E. Breat hing a rnixt ure of 21% 0 , and 79% sulfur hexafl uoride (mol ecular
weight 146).
14. A normal subject makes an inspiratory effort against a closed airway. All of
the following staternents are true EXCEPT:
A. Tensionin the diaphragmincreases.
B. The external intercostal muscles become active.
C. Int rapleural pressure falls.
D. Alveolar pressure falls more than intrapleural pressure.
E. Pressure inside t he pulrnonary capillaries f alls.
Control of Ventilation
How 605 Exchange 15 Regulated
cy. All of
Central Controller
Other Parts of the Brain
Central Chemoreceptors
Peripheral Chemoreceptors
Lung Receptors
Other Receptors
Integrated Responses
Response to Carbon Dioxide
Response to Oxyge n
Response to pH
Response to Exercise
Abnormal Patterns of

Wehaveseenthat the chief function of the lungis to exchange O
betweenbloodandgasand thusmaintainnormal levels of P0
and PC02 in the
anerial blood. In this chapter we shall seethat in spiteof widely differing
demands for O
output madeby the body, the eneriet P0
Pe02 are normallykept within closelimits. This remarkable regulation of gas
exchange is madepossible becausethe level of ventil ation is so carefully
controlled. First we look at the central controller, and then the various
chemoreceptors and other receptors that provideit with information. The
integratedresponses to carbon dioxide, hypoxia andpHare thendescribed.
Cent ral controll er
Inout / Pons, medulla, ~ O u t D l ;
/ other parts at brain ~ t
Sensors 1 ..--hhhhu-nn-n-nn--- 1Eff ectors I
tung and other receptors
Respiratory muscles
Fig ure 8-1. Basic elements of t he respi rat ory control system. Infor mat ion from
various sensors is fed to the centra l controll er, the ou t put of which goes t o t he res -
piratory muscl es. By changi ng vent il ation, t he respi ratory muscles reduce pertur-
bations of t he sensors (negative feed back).
The thr ee basic elements of the respiratory control system (Figure 8, 1) are:
1. Sensors which gathe r informationilnJ feed it to the
2. Central controller in the brain which coordinates th e infor mation and, in
tum, sends impulses to the
3. Effecwrs (respiratory muscles) which cause ventilation.
We shall see that increased act ivity of th e effecto rs generally ultimatel y de-
creases the sensory input [0 the brain, for example, by decreasing the arterial
. This is an example of negati ve feedback.
Central Controller
The normal automat ic process of hreathing originates in impulses that come from
the brainsrcm. TIl e cortex can override these centers jfvoluntarycontrol is desired.
Additional input from other parts of the brain occurs under certain condit ions.
The periodic nature of inspiration and expirat ion is controlled by neurons locat ed
in the pons and medulla. These have been designat ed respirator)' centers. How,
ever, these should not be thought of as discrete nucl ei but rather as somewhat
poorl y defined collect ions of neurons with various components.
Three main groups of neurons are recognized.
1. l\.1edullary resprmrory center in the reticular format ion of the medulla be,
neath the floor of the fourth ven tricl e. This comprises two ident ifiable areas. One
group of cells in the dorsal region of the medull a (dorsal respiratory group) is
chiefly associat ed with inspi rat ion; the ot he r in the ventral area (ventral respira-
tory group) is mainly for expirat ion. One popular (rbough not universally ac-
cepted) view is tha t the cells of the ins/JirawT)' area have the propert y of intrinsic
periodic firing, and they are responsible for the basic rhythm of vent ilat ion,
When all known afferent stimuli have been abolished, these inspirarory cells gen-
erate repeti tive bursts of act ion pot entials that result in nervous impulses going to
the diaphragm and other inspiratorv muscles,
The intrinsic rhythm pattern of the inspiratory area start s with a latent period
of several seconds during whi ch there is no activity. Acti on pot enti als then begin
to appear, incre asing in a crescendo over the next few seconds, During this time,
inspirator y muscle act ivity becomes stronger in a "rarnp'l-tvpe pattern . Finally,
the inspiratory act ion pot entials cease, and inspiratory muscle tone falls to its
prctnspirarorv level .
The inspiratory ramp can be "turned off " premat urely by inhibit ing impul ses
from the pneumotaxic center (see bel ow) . In this way, inspirat ion is shortened and,
as a consequenc e, the brcathinu rate increases. The output of the inspiraror y cells
is further modu lated by impul ses from the vagal and glossopharyngeal nerves. In-
deed, these ter minate in the tractus solirarius, whi ch is situated close to the in-
spirarory area.
The expiraw'!)' area is quiescent J uring normal qu iet breat h ing because vent i-
lat ion is the n achieved by acti ve contract ion of inspi rat ory muscl es (chiefly the
diaphragm), followed by passive relaxation of th e chest wall to its equilibrium po-
sit ion (Chapte r 7). However, in more forceful breathing, for example, on exe r-
cise, expirat ion becomes acti ve as a result of the activity of the expiratory cells.
Nore that there is st ill not uni versal agreement on how the intrinsic rhyt hmicity
of respirati on is brought abo ut by the medullar y centers.
2. Apneusticcenter in the lower pons. This area is so na med because if the brain
of an experimental animal is sectioned just above this site, prolonged inspiratory
gasps (apneuses) interrupt ed by transient expirato ry efforts are seen. Apparent ly,
the impul ses from the center have an exci tatory effect on the inspi rat ory area of
the medulla, tending to prolong the ramp action potent ials. Whether this ap-
neustic center plays a role in normal human respiration is not known, although
in some types of severe brain injur y, thi s type of abnormal breat hing is seen,
3, Pneumomnc center in the upper pons. As ind icated above, this area appears
to "switch off " or inh ibit inspirat ion and thus regulate inspirat ion volume and,
secondarily, respiratory rate. Thi s has been deruonsrrat ed experimentally in ani-
mals hy direct electrical st imulat ion of the pneumotaxic center. Some investt ga-
tors believe that the role of this cent er is "fine tuning" of respi ratory rhythm be-
cause a normal rhythm can exist in the absence of this cent er.
Breathing is und er voluntary control to a considerable extent, and the cortex can
overr ide the function of the brainstem with in limits, It is not difficult to halve the
arter ial P
, by hypervent ilat ion, although the consequen t alkalosis may cause
tetany with contract ion of the muscles of the ha nd and foot (carpopedal spasm),
Halving the P
increases rhe art erial pH by about 0.2 unir (Figure 6-8).
Voluntary hypoventt lanon is more difficult . The dura t ion of breath-holding is
[uni ted by several factors, incl uding the arterial P O ) l and Po z- A preliminary
Respiratory Centers
• Responsible for generating the rhythmic pattern of inspiration and
• Located in the medulla and pons of the brain stem
• Receive input from chemoreceptors. lung and other receptors. and the
• Major output is to the phrenic nerves
period of hyper ventilat ion increases breath-holding t ime, espec ially if oxygen is
breathed. However, factors othe r than chemical are involved. This is shown by
the observation that if at the breaking point of breath-hold ing, a gas mixt ure is
inh aled that raises the arterial P
and lowers the POl ' a further period of breath-
holding is possible.
Other Parts of the Brain
Othe r parts of th e brain, such as the limbic system and hypothalamus. can alter
th e pattern of breathi ng, for example, in emotional stat es such as rage and fear.
The muscles of respiration includ e the diaphragm, inte rcostal muscles, abdomi-
na l muscles, and accessory muscles such as the sternomasroids. The act ions
of these were described at the heginn ing of Chapter 7. In the context of the
control of vent ilation, it is crucially import an t that these various muscle groups
work in a coordinated manner, and this is the responsibi lity of the central
controller. There is evidence th at some newborn children, particularly those
that are premature, have uncoordinated respiratory muscle act ivity, especially
during sleep. For example, the thoracic muscles may try to inspire while the
abdominal muscles expire. Thi s may be a factor in the "sudden infant death
Central Chemoreceptors
A chemorecept or is a receptor that respond s to a change in the che mical compo-
sit ion of the blood or other fluid around it. The most important recept ors in-
volved in the min ute-by-minut e control of vent ilat ion are those situated near the
vent ral surface of the medull a in th e vicinity of the exit of the 9th and l Oth
nerves. In animals, local applicat ion of H+ or dissolved CO
to this area st tmu-
lares breat hing within a few seconds. At one t ime, it was t hought that the
medullary respirator y center itself was the site of action of CO
, hut it is now ac-
cepted that the chemoreceprors arc anato mically separate. Some evidence sug-
gem that they lie about 200 to 400 11m below the ventral surface of the medulla
(Figure 8-2).
= I l l " ~
Brain '
Figure 8·2. Environment of the central chernoreceptors . They are bathed in brain
extracellular fluid (ECFl, through which CO
easily diffuses from blood vessels to
cerebrospinal flui d (CSF). The CO
reduces the CSF pH, thus stimulating the
chemoreceptor. H'" and HC0
ions cannot easily cross the blood-brain barrier.
The central che moreceptors arc surrounded by brain extracellular fluid and re-
spond to changes in its H+ concentration. An increase in H+ concentration
stimulates ven tilation, whereas a decrease inhibits it . The composition of the ex-
tracell ular fluid around the receptors is governed by the cerebrospinal fluid
(CSF), local blood flow, and local metabolism.
Of these, the CSF is apparently the most important . It is separat ed from th e
blood by the blood-brain barrier. which is relat ively impermeable to H+ and
HCO, ions, although molecular CO, diffuses across it easily. When the blood
Peo, t ises, CO, diffuses into the CSF from the cerebral blood vessels, liberating
H+ ions which stimulate the chemoreceprors. Thus, the CO
level in blood reg-
ulates vent ilation chiefly by its effect on the pH of the CSF. The resulting hy-
perventilation reduces the PU)z in the blood and therefore in the CSF. The cere-
bral vasodil ation that accompanie s an increased arterial Pc..'oz enhances diffusion
of CO, into the CSF and the brain extracellular fluid.
The normal pH of rhe CSF is 7.32, and because the CSF cont ains much less
protein than blood, it has a much lower buffering capacity. As a result , the change
in CSF pH for a given change in Peo, is greater than in blood. If the CSF pH is
displaced over a prolonged period, a compensatory change in HCO)" occ urs as a
result of transport across the blood-brain barrier. However, the CSF pH does not
usually ret urn all the way ro 7.32. The change in CSF pH occurs more promptl y
tha n the change of rhe pH of arrerial blood by renal compensat ion (Figure 6.8),
a process that takes 2 to 3 days. Because CSF pH returns to near its normal v a l ~ e
more rapidly than does blood pH, CSFpH has a more import ant effect on changes
in the level of vent ilation and the arterial PCOl" "":,\ -"' .
One example of these changes is a patient with chronic lung disease and CO
retent ion of long standing who may have a nearly normal CSF pH and, therefore,
Central Chemoreceptors
• Located near the vent ral surface of the medulla
• Sensitive to the Peo2 but not P0
of blood
• Respond to the change in pH of the ECF/CSF when CO
diffuses out of
cerebral capillaries
an abnormally low vent ilat ion for his or her arterial PC-Dr A similar situat ion is
seen in normal subjects who are exposed to an atmosphere containing 3% CO
for some J ays.
Peripheral Chemoreceptors
These are located in the carotid bodies at the bifurcation of the common carotid
arte ries, and in the aort ic bodies above and below the aorti c arch. The carot id
bodies are the most important in humans. They conta in glomus cells of two types.
Tvpe I cells show an int ense fluorescent staining because of th eir large content of
'1" ld o p ~ T h e s e cells are in close apposit ion to endings of the afferent carot id si-
nus ner ve (Figure 8-3). The carotid bodyalso contains type II cel ls and a rich sup-
ply of capillaries. The precise mechan ism of the carotid bodies is st ill uncert ain,
but many physiologists bel ieve that the glomus cells are the sites of chemorecep-
tion and that modul ation of neurotransmitter release from the glomus cells by
physiological and chemical st imuli affects the disch arge rate of the carotid body
afferent fibers (Figure 8-3A ).
Figure 8-3. A. Diagram of a caro tid body whic h contai ns type I and type 1\ cells
with many capillaries (Cap). Impulses t ravel to the cent ral nervous syst em (eNS)
through the carot id si nus nerve. B shows the non li near respo nse t o arteri al P 0 2.
Note that the maximum response occurs below a P
0 2
of 50 mm Hg.
The peripheral chemoreceptors respond to decreases in art erial POI and pl-i,
and increases in arterial PCOz. They arc unique among tissues o[the body in that
thei r sensi tivity to changes in arteri al Pazbegins around 500 Hg. Figure 8-3B
shows that the relationshi p between firing rate and art erial Po, is verv nonlinear;
relat ively little response occurs until the arterial P0 2 is reduced below(!.Q9 mm
Hg. but t hen the tate rapidly increases. The carotid bodies have a vet) hi gh blood
flow for their size, and therefore in spite of th eir high metaboli c rate, the arterial-
venous O
difference is small. As a result, they respond to arterial rat her than to
venous P
The response of these receptors can be very fast; indeed, thei r dis-
charge rate can alter duri ng the respiratory cycle as a result of the small cyclic
changes in blood gases. The peripheral chemoreccptors are responsible for all the
increase of ventilat ion that occurs in humans inre§lio nse-tG...at tcrial nYP.9¥ct'; !TIia'. In-
deed, in the absence of these receptors, severe hypoxemia depresses vent ilation,
presumably through a direct effect on the respiratory cent ers. Complete lossof hv-
poxic ventilatory drive has been shown in patients with bilateral carot id body
The response of the peripheral chemorcccptors to arterial P
is less import ant .
than that of the cent ral chemoreccptors. For example, when a normal subject is
given a CO
mixt ure to breathe , less than 20% of the ventilatory response can he
attributed to the peri pheral che morcccpt ors. However, their response
and they may be useful in marchi ng vent ilati on changes in PCOl'
In humans, th e carot id but not t he aort ic bodies respond to a fall in"arierial
pll. This occurs regardless of whether the cause is respiratory or metabolic. Inter-
act ion of the var ious st imuli occurs. Thus, increases in chemoreceptor acti vity in
response to decreases in arterial P<.1z are potent iated by incr eases in and, in
the carotid bodies, by decreases in pH.
lung Receptors
1. Pulmonary Stretch Receptors
These are also known as slowly adapt ing pulmonary stretch recept ors and are be-
lieved to lie within airway smooth muscle. They discharge in response to disrcn-
sion of the lung, and their activity is sustained with lung inflat ion, that is, they
show littl e adaptat ion. The impulses travel in the vagus nerve via large myeli-
nated fibers.
The main reflex effect of sti mulat ing these receptors is a respiratory
frequency due to an increase in expiratory t ime. This is known as the Henng-
reflex. ! t can be well demonstrated in a rabbit preparat ion in
Peripheral Chemoreceptors
• Located in the carotid and aortic bodies
• Respond to decre ased arteri al POz, increased PcOz and H-'-
• Rapidly respond ing
which the diaphragm has a slip of muscle from which recordings can be made
without int erfering with the ot her respi ratory muscles. Classical experiments
showed that inflati on of the lungs tended [Q inhi bit furthe r inspiratory muscle ac-
.1< [ tivity. The opposite response is also seen, t hat is, deflation of the lungs tends to
. initiate inspiratory acti vit y (deflat ion reflex). Thus, these reflexes can provide a
self-regulatory mechanism or negative feedback.
The Hering-Breuer reflexes were once thought to playa major role in ven tila-
t ion by determining the rate anddeprh ofbrearhmg. This could be done by using
the informat ion from these stretch receptor s to modulate the "switching off"
mechanism in the medull a. For example, bilateral vagotomy, which removes the
input of these receptors, causes slow, deep breathing in most animals. However,
more recen t work indicates that the reflexes are largely inact ive in adult hu mans
unl ess.rhe.ridal volume in exerci se. Transient bilateral block-
ado of the vagi by local anesthesia in awake humans does not change either
breathing rat e or volume. There is some evidence that these reflexes maybe more
important in newborn babies.
2. Irritant Receptors
These are thought to lie between airway epithelial cells, and they are st imulated by
noxious gases, cigarett e smoke, inhaled dusts, and cold air. The impulses travel up
the inmyehnared fibers, and the reflex effects include bronchoconsrncti on
andnYI"'... ilmea. Some physiologists prefer to call these receptorst'rapidly adapting
r pulmonary stretch receptors" because they show rapid adapt ation and are appar-
ent ly involved in addit ional mechanoreceptor functions, as well as responding to
noxious stimuli on the airway walls. It is possible that irritant recept ors play a role
-4J in the hronchocOJ:llli.ic;.tion of asthma atta_cks as a result of their response to released
3. J Receptors
These are the endings of nonmyelimited C fibers and somet imes go by t his
name. The term "juxta -capillary," or J, is used because these receptors are be.
lieved to be in the alveolar walls close to the capill aries. The evidence for thi s
locati on is that th ey respond very quickly to chemicals injected into the pul-
monary circul at ion . The impul ses pass up the y"agus nerve in slowly conduct ing
fibers and can resul t in rapid, shallow breathing, although in-
t ense st imulation causes apnea'Vl'here is evidence th at engorgement of pul...
monarv capillaries and in"cr eases in th e interst it ial fluid volume of the alveolar
wall act ivate these receptors. They may play a role in the rapid, sha llowbreath-
ing and dyspnea (sensarion of difficulty in breathing) associated with left heart.
and interstitial lung di sease.
4. Bronchial C-fibers
These are supplied by the bronchi al circulation rather than the pulmonary circu-
lation as is the case for Jreceptors described above. They respond quickly to chem-
icals injected into the bronchial circulation. The reflex responses to stimulat ion
incl ude rapid shallow breathing, bronchcconstrict ion, and mucous secretion.
Other Receptors
1. Nose and Upper Airway Receptors
The nose, nasopharynx, larynx, and trachea contain receptors th at respond to
mechanical and che mica l sti mulat ion. T hese arc an extens ion of th e irrita nt re-
ccprors described Various responses have been described, including
sneezing, coughing, and bronchoconsrrict ion, Laryngeal spasm may occ ur if the
larynx is irritat ed mechanically, for example, dur ing inserti on of an endotracheal
t ube with insufficient local anesthesia.
2. Joint and Muscle Receptors
Impul ses from moving limbs arc bel ieved to he part of the sti mulus to vent ilation
during exercise, especially in the earl y stages.
3. Gamma System
Many muscles, including the intercostal muscles and diaphragm, cont ain muscle
spindles that sense elongation of the muscle. This informacion is used to reflexly
control the strength of cont ract ion. These receptors may be involved in the sensa-
tion of dyspnea that occurs when unusually large respiratory efforts are required ro
move the lung and chest wall, for example, because of airway obstruc t ion.
4. Arterial Baroreceptors
An increase in arterial blood pressure can cause reflex hvpovenulation or apnea
through stimulat ion of the aortic and carot id sinus barorcceptors. Co nve rsely, a
decrease in blooJ pressure may result in hyperventi lat ion. The pathways of these
reflexes are largely unknown.
5. Pain and Temperature
St imulat ion of many afferent nerves can hri ng about changes in ventilat ion . Pain
often causes a per iod of apnea followed by hyperventil ation. Heat ing of the skin
may result in hyperventila t ion.
Integrated Responses
Now that we have looked at the various un its that make up the respiratory con-
trol system (Fib'1.lrC 1), it is useful to consider the overall responses of the system
to changes in rho arterial CO
, O
, and pH and to exercise.
Response to Carbon Dioxide
The most important factor in the control of vent ilation under normal conditions
is the P
e o
) of the arte rial blood. The sensit ivity of th is control is remarkabl e. In
the course-of da ily act ivity with periods of rest and exercise, the arter ial P C0 2 is
probably held to with in 3 mm Hg. Duri ng sleep it may t ise a lit tle more.
The ventila tory response to CO
is nor mally measured by having the subject
inha le CO
mixtures or rcbrcarhe from a bag so that the inspired P
C0 2
rises. In one technique, the subject rehrcathcs from a bag that is prcfllled with 7(X)
CO, and 93% 0 , . As the subject rebreathcs, mcrabolic CO, is added to the
but the O
concentration remains relati vely hi gh. In such a procedure the PI
of the bag gas increases at the rate of about 4 mrn Hg/min.
Figure 8 ~ 4 5hO\\'5 the results of experiments in whi ch the inspired mixture
adjusted to yield a constant alveolar p O]' (In th is type of experiment on no
subjects. alveolar end -tidal Po , and P ~ , are generally taken to refl ect the a
rial levels.} It ca n be seen (ha-[ wit h a normal Po , the ventilation inc reases
about 2- 3 liters/min for each 1 mm Hg rise in PU l l' Lowering the Po z prod
two effects: a higher vent ilat ion for a given P
• and the slope of the line
comes steeper. There is conside rable var iat ion between subjec ts.
Anot her way of measuring respiratory drive is to record the inspirat ory r
sure duri ng a brief period of airway occlusion. The subject breath es rhroug
mouth piece atta ched to a valve box, and the inspiratory port is provided wit
shurrer. This is closed duri ng an expiration (the subject being unaware), so t
the first part of the next inspiration is against an occluded airway. The shutre
opened after about 0.5 sec. The pressure generated during the first 0. 1 sec of
tempted inspiration (known as po.d is taken as a measure of respiratory cen
Alveolar P02
UJ 40
~ 30
~ 20
or 169 .
Alveolar PC02(mm Hg)
Figure 84. Vent i latory response t o CO
, Each curve of total vent il at ion agains
alve olar PC02 is f or a different alveolar P02' In t his stud y, no difference was fou
bet wee n alveol ar P
values of 110 mm Hg and 169 mm Hg, though some i nves
t igators have found t hat t he slope of th e li ne is slight ly less at t he higher P
output. Th is is largely unaffected by the mechanical propert ies of the respiratory
system, although it is influenced by lung volume. This method can be used to
study the respiratory sensit ivity to COl> hypoxia, and other variables as well .
A reduction in arter ial PC:Dz is very effective in reducing the st imulus to vcn- 27
n lation. For example, if th e reader hyperventilat es voluntarily for a few seconds,
he or she will find that there is no urge to breathe for a short period. An anes-
thctizcd pat ient will frequently stop breat hing for a min ute or so if first ovcrven-
tilated by the anesthes iologist.
The vent ilatory response to CO
is reduced hy sleep, increasing age, and ge-
net ic, racial, and persona lity factors. Trained athletes and divers tend to have a
Various drugs depress the respiratory center, including mor-
phi ne and barbiturates. Pat ients who have taken an overdose of one of these drugs
often ha ve marked hypoventilat ion. The vent ilatory response to CO
is also rc-
duced if the of breath ing is increased. This can he demonstrated by ha ving
nor mal subjects bre,;th e th rough-a nar row tube. The neural output of th e rcspira-
tory center is not reduced, but it is not so effective in producing vent ilat ion. The L
abnormally small ventilatory response to COz and the COz retention in some pa-
tients with lung disease can be partly explained by the same mechan ism. In such
patients, reducing the airway resistan ce wit h bronchodilarors often increases
their ventilatory response. There is also some evidence that the sensitivity of the
respirator y center is reduced in these pat ient s.
------- 7 As we have seen, the main stimulus to increase venti lat ion when the arterial
I'co , rises comes from the central chc rnoreceptors, whic h respond to the in-
creased H+ concentrati on of the brain ext racellular fluid ncar the receptors. An #<
addit ional stimulus comes from the peripheral chemoreceptors, because of both
the rise in arterial P
and the fall in pH. +:
Response to Oxygen
The way in whic h a reducti on of Poz in art erial blood st imulates vent ilat ion can
be studied by having a subject breathe hypoxic gas mixtures. The end-tidal POl
and P
, are used as a measure of the arteria l values. Figure shows that when
the Pa l z is kept at about 36 mm Hg (by altering the inspired mixt ure),]
the alveolar po! can be reduced to the vicinity of 50 mm Hg before any
ciablc increase in vent ilation occurs. Raising the P
increases the vent ilat ion ellS
at any P Ol (compare Figure 8-4 ). Note that when the P
is increased, a reduc- -
t iOll Tr=t PO l below 100 mm Hg causes some sti mulation of ventilat ion, unlike the
Ventilatory Response to Carbon Dioxide
• Arterial Pco
is the most important stimulus to ventilat ion under most con-
ditions and it is normally tightly controlled
• Most of the stimulus comes from the central chemoreceptors but the
peripheral chemoreceptors also contribute and thei r response is faster
• The response is magnified if the arterial P0
is lowered
40 CD

<, Peo:!


C 20
43 7


--- ------------
20 40 60 80 100 120 140
Alveol ar P02(mm Hg)
Figure 8-5. Hypoxi c response curves. Note th at when t he Pco, is 35.8 mm Hg,
almost no i ncrease in vent i lat ion occurs unt i l t he P 0 2 is red uced to about 50
mm Hg.
situa tion in which the P
C0 1
is normal. Thus, the combined effects c!lbpthsrim;
?uli exceed th e sumofeach given and thi s is referred to as
I teraction between the hi gh CO
and low Ojstimuli. Large differences in response
occur between individual subjects.
Because the POzcan normally be reduced so far without evoking a vent ilatorv
response, the role of this hypoxi c st imulus in the dav-ro-dav contro l of venti la-
(ion is sma ll. However, on ascen t to hi gh alt itude, a large increase in vent ilation
occurs in response to the h ypoxia (see Chapter 9).
In some pat ients with severe lung disease, th e hypoxic dri ve to ventilat ion be,
/ comes very important . These patients have chronic CO
retenti on, and the pH
of their brain extrace llular fluid has returned to near normal in spite of a raised
co z
. Thus, they have lost most of their increase in the st imulus to vent ilat ion
from CO
, In additi on, the initial depression of blood pH has been nearly abol -
ished by renal compensat ion so that th ere is little pH st imulat ion of the pcr iph-
eral chemoreceptors (see below). Under these conditions, the art erial hypoxemi a
becomes the chief stimulus to vent ilation. If such a pati ent is given a high 0 .:
mi xture to breathe to relieve the hypoxemia, vent ilation may become grossly de-
pressed. The ventilatory state is best monitored bymeasuring arterial PC"'l) , '
As we have seen, hypoxe mia reflexly st imulate s ventila tion by its act ion on
the carot id and aor t ic body chcmoreceprors. It has no act ion on the central
chemoreceptors; indeed, in the absence of peri pheral chemoreceptors, hypoxemia
depre sses respirat ion. However, prolonged hypoxemia can cause mild cerebral
acidosis, which, in rum, can stimulate ventilation.
Ventilatory Response to Hypoxia
• Only the peripheral chemoreceptors are involved
• There is negligible cont rol during normoxic conditions
• The control becomes important at high altitude, and in lonq-terrn hypoxemia
caused by chronic lung disease
Response to pH
A reduct ion in art erial blood pH st imulates ventilation. In pract ice, it is often dif-
ficult to separate the vent ilatory response resulting from a fall in pH from that
caused by an accompanying rise in Pcoz' However, in experimental animals in
which it is possible to reduce the pH at a constant Pcoz' the st imulus to venula-
tion can be convincingly demonstrated . Pat ient s with a partl y compensated
metabolic acidosis (such as uncontrolled diabet es mellitus) who have a low pH
and low P
(Figure show an increased vent ilation. Indeed, thi s is respon-
sible for the reduced P= ,.
As we have seen, the chief site of act ion of a reduced arterial pH is the penph-
eral chc moreceprors. It is also possible that the central chemoreceptors or the
piratory cente r itself can be affected by a change in blood pl-l if it is large enough. I"
In this case, the blood-brain barrier becomes partl y permeable to H+ ions. .-J
Response to Exercise
On exercise, ventilation increases promptly and during strenuous exert ion may
reach very high levels. Fit young people who att ain a maximum O
consumpt ion
of 4 liters/min may have a total vent ilat ion of 120 liters/min, that is. about 15 _
times their resting level. This increase in vent ilat ion Closely ma-tches the increase .
uptake and CO
output. It is remarkable that the cause of the increased
ventilation on exercise remains largely unknown.
The arterial PC02- during exercise; indeed, during severe ex-
ittypicall yfalls slight lY. The arter ial P
O z
usually increases slightly, although
it may fall at very high work levels. The arterial pH remains nearly constant for
moderat e exercise, alt hough during heavy exercise it falls because of the libera-
tion of lacti c acid through anaerobic glycolysis. It is clear, therefore. th at none of
the mechanisms we have discussed so far can account for the large increase in
vent ilat ion observed dur ing light to moderat e exercise.
Other st imuli have been suggested. Passive movemenrof rhe.lnnbs st imulates
vent ilat ion in both anesthet ized animals and awake humans. This is a reflex with
receptors presumably located in joints or muscles. it may beresponsible for the
abrupt increase in vent ilation duri ng theJirg fu-wseconds of exerc ise.
One hypothesis is thaf (lli;illations in arterial P0 2 ani Pcu:-may
chemoreceptorsfeveri 'though the mean level remains unaltered. These
fluctuat ions are caused by the periodic nature of vent ilat ion and increase when
the tida l volume rises, as on exercise. Anot her theory is that the central chemore-
ceptors increase vent ilation to hold thfGrterial by some kind of

• I
servomechanism, just as the thermostat can control a furnace with littl e change
in temperature. The object ion that the arterial P
often falls Inexercise is
~ + countered bv the assert ion that the preferred level of P c o ~ is' r e ~ in some way.
, Proponents ~ f this theory believe that the ventilato ry response to inhaled COl
may not be a rel iable guide to wha t happens on exercise.
- - ..... yet anoth er hypothesis is that vent ilat ion is linked in some way to the addi-
t ion al COz loadpresented [Q the lungs in the mixed venous blood during exercise.
In animal experiments, an increase in this load produced ei th er byinfusing COl
into the venous blood or byincreasing veno us return has been sho wn to correl ate
well with vent ilat ion. However, a problem with th is hypothesis is that no suitable
receptor has been found.
Additiona l factors that have been suggested incl ude the increase in bod)' tem-
peraturedur ing exercise, which stimulates ventilation, and impulses from the motor
cortex. However , none of the theories proposed so far is completely satisfactory.
Abnormal Patterns of Breathing
Subjects with severe hypoxemia often exhibit a str iking pattern of per iodic
breathing known as Che)'ne-Swkes respiration. This is cha racterized by periods of
apnea of 10 to 20 sec, separated by approximately equal periods of hyperventila-
t ion when the tidal volume gradually waxes and then wanes. Thi s pat tern is fre-
quently seen at high alt itude, especially at night during sleep. It is also found in
some patients with severe heart di sease or brain damage.
The pattern can be reproduced in experimental ani mals by lengthening the
distance through which blood travels on its way to the brain from the lung. Un-
der these condit ions, the re is a long delay before t he central chemoreceprors sense
the alterat ion in P
eo z
caused by a change in ven tilat ion. As a result , the respira-
tory center hunts for the equilibrium condition, always overshoot ing it. However,
not all instances of Cheyne -Stokes respira tion can he explained on this basis.
Other abnormal patte rns of breathing can also occur in disease.
For each quest ion, choose the one best answer.
1. Whi ch of the following st atements about the respi ratory centers is FALSE?
A. The normal rhythmic patt ern of breathing originates from neurons in the
pons and medulla.
B. Inspiratory act ivity originates in the dorsal respiratory group of cells in
the medulla.
C. Impul ses from the pneumotaxic center can switch off inspirat ory
D. The cortex of the brain can override the function of the respiratory cen-
t ers.
E. The only output from the respiratory cent ers is via the phrenic nerves.
2. All of t he following stat ements about t he cent ral chemoreceptors are t rue
A They are locat ed near the vent ral surface of the medulla.
B. They respond to both t he Pea, and the Po, of the blood.
C. They are act ivated by changes in t he pH of the surrounding extracellular
fluid .
D. For a given rise in Peo2 the pH of cerebrospinal fluid falls more than that
of blood.
E. If t he Peo, of t he blood is increased for a long time. the pH of the CSFis
ret urned to near normal by movement of bicarbonate into it .
3. Which of the foll owing statement s about t he peripheral chemoreceptors IS
A. They respond t o changes in arterial Po-. Peo, and pH.
8. Under norrnoxic condit ions the response to changes in P0
is very small.
C. The response t o changes in Peo2 is faster than f or cent ral
D. They are t he most important receptors causing an increased vent ilati on
in response to a rise in PC02.
E. They have a high bl ood flow per gram of tissu e.
4. All of t he following statement s about the vent ilatory response to carbon
dioxide are t rue EXCEPT:
A. It is increased if t he alveolar P0
is raised.
B. It depends on both t he peripheral and cent ral chemoreceptors.
C. It is reduced during sleep.
D. It is reduced if t he work of breathi ng is increased.
E. It is a major fact or cont rolling t he normal level of vent ilat ion.
5. All of the following statements about t he venti latory respons e to hypoxi a are
true EXCEPT:
A. It is t he major stimulus to ventilation at high alt itude.
B. Venti lat ion is inhibited if 100% oxygen is breat hed.
C. It increases if the PC02 is raised.
D. It may be a maj or stimulus to vent ilat ion in patients with severe chronic
lung disease.
E. It does not play a role in mild carbon monoxide poisoning.
6. The most important st imulus controlling t he level of rest ing venti lation is:
A. P0
on peripheral chemorecept ors.
B. PC0 2 on peripheral chemorecept ors.
C. pH on peripheral chemorecept ors.
D. pH of CSFon central chemorecept ors.
E. P0
on central chemoreceptors.
7. Exercise is one of t he most powerful stimulat ors of vent ilation. It primarily
works by way of :
A. Low arterial Po, .
B. High arterial Pco- .
C. Low P0
inmixedvenous blood.
D. Low arterial pH.
E. None of the above.
8. All of the foll owin g statements about the Hering-Breur inflation reflex are
true EXCEPT:
A. The impulses travel to the brain via the vagus nerve.
B. It results in further inspiratory efforts if the lung is maintained inflated.
C. It is onl y seen in adults at high tidal volumes.
D. It may help to inflate the newborn lung.
E. Abolishing the reflex in many animals causes slow deep breathing.
Respiratory System
Under Stress
HowGas Exchange Is Accomplished During Exercise. at low
and High Pressures, and at Birth
High Altitude
Pol ycythemi a
Ot her Features of
Oxygen Toxicity
Absorpt ion Ate lectasis
Space Flight
Increased Pressure
Decompression Sickness
Inert Gas Narcosis
Hyperbaric O
Polluted Atmospheres
Liquid Breathing
Perinatal Respiration
Place ntal Gas Exchange
The First Breat h
Circulatory Changes
The normal lung has enormous reserves at rest, andthese enable it tomeet the
greatly increased demands for gasexchange during exercise. In addition, the
lung servesas our principal physiological link with theenvironment thatwe live
in;itssurface area is some30times thatof theskin. The human urge toclimb
higher anddive deeper putstherespiratory system under great stress, although
thesesituations areminor insults compared with theprocess of being born!
The gas excha nge demands of the lung are enormously inc reased by exercise.
ically, the resti ng oxyge n consumptions of 300 ml /min can rise to about 3000
ml/min in a moderately fit subject (an d as hi gh as 6000 ml/min in an elite athlete).
Similarly, the rest ing CO
output of, say, 240 ml/min increases to about 3000
ml/min. Typically, the respiratory exchange rati o (R) rises from about 0.8 at rest
(0 1.0 on exercise. This increase reflects a greater reli anc e on carbohydr are rathe r
than fat to prod uce the required energy. Indeed, R ofte n reaches even hi gher lev-
els dur ing the unsteady state of severe exercise when lact ic acid is produced by
anaerobic glycolysis and addit iona l CO
is the refore el iminated from bicarbonate.
In addi tion, there is increased CO
eliminat ion because the increased H+ can,
ce nrration st imulates the peripheral chemoreceptors thus increasing venti lation.
Exercise is conveniently studied on a treadmi ll or stationary bicycle. As work rare
(or power) is increased, oxygen uptake increases linearly (Figure However,
above a certa in work rate, VOzbecomes constant; thi s is known as the Vozmax. An
increase in work rate above this level can occur only th rough anaerobic glycolysis.
Vent ilat ion also increases linearly ini tia lly whe n plotted against work rate or
0 2
' but at high V
0 2
values, it increases more rap idly bec ause lact ic acid is libel"
ated, and this increases the vent ilatory st imul us (Figure 9,I B). Somet imes there
is a clear break in the slope, and thi s has been called anaerobicrhreshold, altho ugh
the term is somewhat controversial. Unfit subjects produce lactate at rel at ively
10\\1 work level s, whereas well-trai ned subjects can reach fairly high work levels
before substantial anaerobic glycolysis occ urs.
Many functions of th e respiratory system cha nge in response to exe rcise. The
diffusing capacit y of the lung increases because of increases in both the diftus-
4 "E 150
:5 10
Vo..max Q.
• E




La /


/ iil

0 0
0 100 200 300
0 2 4
A Work rate (watts) B ilo, (Il min)
Figure 9·1. A. O
co nsumpt ion (V
) i ncreases nearl y lin earl y with work rat e until
t he V
o 2
max is reached. B. Vent ilat ion initi al ly i ncreases lin earl y wit h O
tion but rises more rapidl y w hen substant ial amount s of bloo d lact ate are for med.
If there is a cl ear break, this is somet imes called the an ae rob ic th res hold (ATI. Car-
di ac outp ut increase s more slowly th an ventilat ion.
ing capacity of the membrane, D ~ v j , and the volume of blood in the pulmonary
capillaries, Y
. These changes arc brought about by recruitment and distension
of pulmonary capillaries, particularly in the upper part s of the lung. Typically,
the diffusing capac ity increases at least th reefold. Never the less, some eli te ath-
letcs at extremely high work levels show a fall in arterial Po , caused hy diffusion
(imitat ion. ..
Ca rdiac output increases approximately linearly with work level as a result of
increases in both heart rate and stroke volume. However, the change in cardiac
output is only about a quarter of the increase in vent ilation (in l/min). This makes
sense because it is much easier to move air than to move blood. If we look at
the Fick equat ion, VOl = Q(CU("1 z - Cvoz), the increase in V0
is brought about
by both an increase in cardiac output and a rise in arterial-venous O
because of the fall in the oxygen concentrat ion of mixed venous blood. By con-
trast , if we look at the analogous equatio n for vent ilation, Voz = \'E (Flo z -
FF.QZ), the difference between inspired and expired O
concentrations docs not
change. This is consistent with the much larger increase in vent ilat ion than
blood flow. The increase in cardiac output is associated with elevations of both
the pulmona ry artery and pulmonary venous pressures, whi ch account for the re-
cruitment and distension of pulmonarycapillaries. Pulmonary vascular resistance
In norma l subjects, the amount of vcntilanon-perfusion inequality decreases
durin g moderate exercise because of the more uniform topographical distribution
of blood flow. However, because the degree of ven rilarion-pcrfusion inequality in
normal subjects is tr ivial, th is is of little consequence . There is some evidence
that in elite athletes at very high work levels, some vent ilat ton-perfusion in-
equa lity develops, possibl y because of mild degre es of interst iti al pulmona ry
edema. Ce rtainly, fluid must move out of pulmonary capillaries heca use of the in-
creased pressure within them.
The oxygen dissociat ion curve moves to the right in exercising muscles be-
cause of the increase in PC0 2' H+ concentrat ion, and temperature. This assists
the unloadi ng of oxygen to the muscles. When the blood retu rns to the lung, the
temperature of the blood falls and the curve shifts leftward somewhat. In some an-
imals such as horses and J ogs, the hematocrit increases on exercise because red
cells arc eject ed from t he spleen, but this docs not occur in humans.
In peripheral tissues, additional capillaries open up, thus reducing the diffusion
pat h length to the mitochondria. Peripheral vascular resistance falls because the
large increase in cardiac output is not associated with much of an increase in
mean arterial pressure, at least during dynamic exercise such as running. During
static exercise such as weightlifting, large increases in systemic arterial pressure
often occur. Exercise training increases the number of capillaries and rnitochon-
dria in skeletal muscle.
As we saw in Chapter 8, th e very large increase in ventilation that occurs dur-
ing exercise is largely unexp lained. However, th e net result is that th e arterial
Po" P= " and pH are littl e affected bymoderate exercise. At very high work lev-
els, P= , often falls, Po, rises, and pH falls because of lactic acidosis.
Altitude (ff)
a 10000 20000
Sea level
E 600
l' a.
0 50
l' ·C
200 Mt. Everest
a 2000 4000 6000 8000
Altit ude (m)
Figure 9-2. Rel ati on ship between altitude and baromet ric pressu re. Note t hat at
1520 m (5000 tt l (Denver, CO), the P0 2 of moist i nspi red gas is abo ut 130 mm Hg,
but is only 43 mm Hg on th e summit of Mount Ever est .
High Altitude
The barometri c pressure decreases with distance above the eart h' s surface in an
approximately exponential manner (Figure 9-2). The pressure at 5800 m (19,000
fr) is only one-half the normal 760 mm Hg, so the POz of moist inspired gas is
(380 - 47) X 0.2093 = 70 mm Hg (47 mm Hg is the parti al presslire of water va-
por at body temperature). At the summit of Mount Everest (altitude 8848 m or
29,028 fr), the inspired Po, is only43 mm Hg. At 19,200 m (63,000 fr), the baro-
metric pressure is 47 mm Hg so that the inspired POz is zero .
In spite of the hypoxia associated with high alt itude, some 140 million people
live at elevat ions over 2500 m (8000 ft ), and permanent residents live hi gher
than 4900 m (16,000 fr) in the Andes. A remarkable degree of acclimatizat ion oc-
curs when humans ascend to these alt itudes; indeed, climbers have lived for SC\, I
era] days at altitudes that would cause unconsciousness within a few seconds in
the absence of acclimat izat ion.
The most important feature of accl imat ization to high altitude is hvpervenril a-
t ion. Its physiological value can be seen by consider ing the alveolar gas equat ion
for a climber on the summit of Mount Everest. If the cl imber's alveolar Pea l
were 40 and respirato ry exchange rat io 1, the climber's alveolar Po , would be
43 - (40/ 1)* = 3 mm Hg: However, by increasing th e climber's vent ilat ion five'
fold, and thus reducing the cl imber's P
, to 8 mm Hg (see p. 18), rhe cl imber
can raise h is or her alveolar POz to 43 - 8 = 35 mm Hg. Typically, the arterial
Peo, in permanent residents at 4600 m ( 15,000 fr) is about 33 mm Hg.
The mechanismof the hyperventilarion is hypoxic srimulation of the peripheral
chemoreceptors. The result ing low art erial P C'02 and alkalosis tend to inhibit this
increase in ventilation, but after a day or so, the cerebrospinal fluid (CSF) pH is
brought part ly back by movement of bicarbona re out of the CSF, and after 2 or 3
days, the pH of the arterial blood is returned to near normal byrenal excretion of
bicarbonate. These brakes on ventilation are then reduced, and it increases further.
In addit ion, there is now evidence that the sensitivity of the carotid bodies to hy-
poxia increases dur ing accl imatization. Interestingly, people who are bor n at high
alt itude have a diminished ventilatory response to hypoxia that is only slowly cor-
rected bysubsequent residence at sea level. Conversely, those born at sea level who
move to high altit udes retain their hypoxic response intact for a long time. Appar-
cntly, therefore, thi s ventilatory rcsponse is det ermined very early in life.
Another apparently valuable feature of accl imat izat ion to h igh alti tude is an in-
crease in the red blood cell concentrat ion of the blood. The result ing rise in
hemoglobin concentration, and the refore capaci ty, means that al-
though the arter ial Poz and O
saturat ion arc dimini shed, the O, con centrat ion
of the arterial blood may be nor mal or even above normal. For example, in per-
manent residents at 4600 m (15, 000 ft) in the Peruvian Andes, the arterial PO,
is only 45 mm Hg. and the correspon ding arteri al O
saturat ion is on ly 81%. Or-
dinarily, this would considerably decrease the arterial O
concentrat ion, but be-
cause of the polycythemia , the hemoglobin concentrat ion is increased from 15
to 19.8 gm/ IOOml, giving an arterial 0, concentration of 22.4 ml/l OOml, wh ich
is act ually higher than the nor mal sea level value. The polycythemia also tends
to maintai n the P
of mixed venous blood, and typically in Andean na t ives ltv-
ing at 4600 m (15,000 fr), thi s Po , is only 7 mm Hg below normal (Figure 9-3).
The st imulus for the increased producti on of red blood cells is hypoxemia, which
releases erythropoie t in from the kidney, wh ich in turn stimulat es the bone mar-
row. Polycythe mia is also seen in many patients with chronic hypoxemia caused
by lung or heart disease.
Although the polycythe mia of hi gh alt itude increases the Os-carrvi ng capac-
ity of the blood, it also raises the blood viscosity. This can be del eterious, and
some physiologists believe that the marked polycythe mia that is someti mes seen
is an inappropriate response.
Other Features of Acclimatization
There is a rightward shift of the O
dissociation curve at moderate altitudes that
results in a better unloading of O
in venous blood at a given P
. The cause of
the shift is an increase in concentration of 2,3-diphosphoglycera te, which devel-
ops primarily beca use of the respirato ry alkalosis. At highe r altitudes there is a
leftwardshift in the dissoc iati on curve caused by the respiratory alkalosis, and this
assists in the loading of 0, in the pulmonary capillaries. The number of capillaries
Arterial Mixed venous
blood blood
Figure 9-3. POz val ues fr om i nspi red ai r t o mixed venous blood at sea level and i n
resident s at an alt it ude of 4600 m (15,000 ttl. Note t hat in spi te of t he much lower
i nspi red POz at alt it ude, the P
of t he mi xed venous blood is on ly 7 mm Hg lower.
per unit volume in peripheral tissues incr eases, and changes occur in the oxidatit'e
enzymes inside the cells. The maximum breathing capad t)1increases because the air
is less dense, and this assists the very hi gh ventilations (up to 200 liters · min- 1)
that occur on exercise. However, the maximum O
uptake declines rapidl y above
4600 m (15,000 ft) . This is corrected to a large extent (though not completely) if
100% 0 , is breathed.
Pulmonary vasoconstriction occurs in response to alveolar hypoxia. This in-
creases the pulmonary arte rial pressure and the work done by the right heart. The
hypertension is exaggerated bythe pol ycythemia which raises the viscosity of the
blood. Hypertrophyof the right heart isseen with characteristic changes in the elec-
trocardiogram. There seems to be no physiological advamage in thi s response, ex-
Acclimatization to High Altitude
• Most important feat ure is hyperventi lation
• Polycythemia is slow to develop and of mi nor value
• Other features include increases in cellular oxidative enzymes and the
concentration of capillaries in some tissues
• Hypoxic pulmonary vasoconstriction is not beneficial
cept that the topographical distribution of blood flowbecomes more uni form. The
pulmonary hypert ension is somet imes associated with pulmona ryedema, although
the pulmonary venous pressure is normal. The mechanismfor this is uncertain, but
one hypothesis is that the arteriolar vasoconstrict ion is uneven, and leakage occurs
in unprotected, damaged capillaries. The edema fluid has a high protein concen-
tration, indicat ing that the permeability of the capillaries is increased.
Newcomers to high altitude frequentl y complain of headache, fatigue, diaai-
ness, palpitations, insomnia, loss of appetite, and nausea. This is known as acute
mountain sickness and is at tributable to the hypoxemia and alkalosis. Long-term
residents somet imes develop an Ill-defined syndrome characterized by marked
polycythemia, fatigue, reduced exercise tolerance, and severe hypoxemia. This is
called chronic mountain sickness.
The usual problem is gett ing enough O
into the body. but it is possible to have
too much . When high concentrat ions of O
are breat hed for many hours, damage
to the lung may occur. [f guinea pigs are placed in 100% O
at atmospheric pres-
sure for 48 hours, they develop pulmonary edema. The first pathological changes
are seen in the endothelial cells of the pulmonary capi llaries (see Figure 1-1). Ir
is (perhaps fortunately) difficult to administer very high concentrat ions of O
pat ient s, but evidence of impaired gas exchange has been demonstrated after 30
hours of inhalat ion of 100% 0 ,. Normal volunt eers who breathe 100% 0, at at -
mosphe ric pressure for 24 hours complain of substernal distress that is aggravated
by deep breathing, and they develop a dimi nut ion of vital capacity of 500 to 800
ml. This is probably caused by absorpt ion atelectasis (see below).
Ano ther hazard of breathing 100% O
is seen in premature infan ts who de-
velop blindne ss because of retrolental fibroplasia, t hat is, fibrous tissue forma-
tion behind the lens. Here the mechanism is local vasoconstriction caused by
th e high P0 2 in t he incubat or, and it can be avoided if the art erial POl is kept be-
low 140 mm Hg.
Absorption Atelectasis
This is anothe r danger of breat hing 100% O
, Suppose that an airway is ob-
structed by mucus (Figure 9-4) . The total pressure in th e trapped gas is close to
760 mm Hg (it may be a few mm Hg less as it is absorbed because of elastic forces
in the lung). But th e sum of the part ial pressures in the venous blood is far less
than 760 mm Hg. Thi s is because th e Po, of the venous blood remains relatively
low, even when O
is breathed. In fact , the rise in O
concentration of arterial and
venous blood when O
is breathed will be the same if cardiac output remains
unchanged, but because of the shape of the O
dissociati on curve (see Figure
6-1), the increase in venous n .) z is only about 10 to 15 mm Hg. Thus, because
th e sum of the part ial pressures in the alveolar gas greenly exceeds th at in the vc-
nous blood. gas diffuses into the blood, and rapid collapse of the alveoli occurs.
Reopening such an atelectatic area may be di fficult because of surface tension
effects in such small units.
CO, (40)
N, 573
H, O -.£..
Total 760
CO, 45
Total 760
0 47
Total 147
.' .,
Figure 9-4. Reasons for atel ectasis of alveol i beyond blocked airways when O
and when air (B) is breathed. Note that i n both cases, t he sum of t he gas partial pres-
sures in the mixed venous blood is less t han in the alveolL ln B, the P02and Pee, are
shown i n parentheses because these values change wit h ti me. However , t he t ot al
alveolar pressure remains wit hin a few mm Hg of 760.
Absorpt ion co llapse al so occurs in a blocked region even when ai r is
breathed, alrhough here rhe process is slower. Figure 9-4B shows rhat again the
sum of the partial pressures in venous blood is less than 760 mm Hg because the
fall in P0 2 from art erial to venous blood is much greater than the rise in pco! (thi s
is a reflect ion of the steeper slope of the CO
compared with the Oz dissociation
curve-see Figure 6-7) . Because the total gas pressure in the alveoli is near 760
mm Hg, absorpt ion is inevit able. Actually, the changes in the alveolar parti al
pressures during absorpt ion are somewhat complicated, but it can be shown that
the rate of collapse is limited by the rate of absorption ofN
. Because this gas has
a lowsolubilit y, its presence acts as a "splint" that, as it were, supports the alveoli
and delays collapse. Even relati vel y small concentrations of N
in alveolar gas
have a useful splint ing effect. Neverthe less, postoperati ve atelectasis is a common
problem in pat ient s who are treat ed with hi gh O
mixtures. Collapse is particu-
lady likely to occur at the bottom of the lung, where the parenchyma is least well
expanded (see Figure 7-8) or the small airways are act ually closed (see Figure 7-
9). This same basic mechan ism of absorption is responsible for the gradual disap-
pearanee of a pneumothorax, or a gas pocket int roduced under the skin.
Space Flight
The absence of gravity causes a number of physiological changes, and some of
these affect th e lung. The distr ibuti on of vent ilation and blood flow become more
unifor m, with a small corresponding improvement in gas exchange (see Figures 5 ~
8 and 5 ~ 10), though some inequality remains because of nongravi rat.iona ] factors.
The deposition of inhaled aerosol is altered because of the absence of sedirnenta-
rion. In addition, thorac ic blood volume init ially increases because blood does
not pool in the legs and this raises pulmonary capillary blood volume and diffus-
ing capacity. Postural hypote nsion occurs on retu rn to earth; this is known as car-
diovascular deconditioning. Decalcificat ion of bone and muscle atrophy may occur,
presumably through disuse. There is also a small reduction in red cell mass. Space
sickness during the first few days of flight can be a serious operat ional problem.
Increased Pressure
During J iving, th e pressure increases by 1at mosphe re for every 10 m (33 fr) of de-
scent . Pressure by itself is relat ively innocuous, as long as it is balanced.
ever, if a gas cavity such as the lung, middle ear, or intracrani al sinus fails to com-
municat e with the outside, the pressure difference may cause compression on
descent or overexpansion on ascent . For example, it is very important for scuba
dive rs to exhale as they ascend to prevent ovcrinflat ion and possible rupt ure of
the lungs. The increased density of the gas at depth increases the work of breat h-
ing. Thi s may result in COl retention, espec ially on exercise.
Decompression Sickness
During diving, the high part ial pressure of N, forces thi s poorly soluble gas into so-
lution in bodyt issues. This part icularly occurs in fat , \', rhich has a relatively high N
solubility. However, the blood supply of adipose t issue is meager, and the blood can
carry little N
• In addit ion, the gas diffuses slowly because of its low solubility. As a
result , equilibrat ion ofN
between the tissues and the environment takes hours.
During ascent, N
is slowly removed from the t issues . If decompression is un-
dul y rapid, bubbles of gaseous N
form, just as CO
is released when a bottle of
champagne is opened. Some bubbles can occ ur wit hout physiological distur-
bances, but large numbers of bubbles cause pain, especially in the region of joints
("bends"). In severe cases, there may be neurological disturbances such CI S deaf-
ness, impaired vision, and even paralysis caused by bubbles in the central nervous
system (eNS) [hat obstruct blood flow.
The treat ment of decompression sickness is by recompression. This reduces
the volume of the bubbles and forces them back into solut ion, and often results
in a dramat ic reduct ion of symptoms. Preven tion is bycareful decompression in a
series of regulated steps. There are schedules that arc based partl y on theory and
partl y on expe rience and show how rapidly a di ver can come up with little risk of
developing bends. A short but very deep dive may require hours of gradual de-
compression. It is now known that bubble formation during ascent is very corn-
monoTherefore, the aim of the decompression schedules is to prevent the bubbles
from growing t oo large.
t At pressures of hundreds of atmospheres, chemical reactions arc affected. For example,
the Oz dissociation curve is displaced.
The risk of decompression sickness following very deep Jives can he reduced if
a helium-Or mixture is breath ed during the J ive. Helium is about orre-hal f as sol;
uble as N
so that less is dissolved in t issues. In addit ion, it has one-sevent h of th e
molecul ar weight ofN
and therefore diffuses more rapidly th rough t issue (Figure
3- 1). Bot h these factors reduce th e risk of bends. Another advant age of a hel ium-
Oz mixture for divers is its lowdensity, which reduces the work of breathing. Pure
or enriched O
mixtures cannot be used at depth because of the dangers of 0
toxicity (see below).
Commercial divers who arc worki ng at great depths, for example on pipel ines,
somet imes use saturari<m diq,,·ing. When they are not in the water, they live in a
high pressure chamber on the supply ship for several days, which means that they
do not return to normal atmospheric pressure during this t ime. In this way they
avoid decompression sickness. However at the end of the period at hi gh pressure,
they may take many hours to decompress safely.
Inert Gas Narcosis
Although we usuall y think of Nj as a physiological inert gas, at hi gh part ial pres;
sures it affects the e NS. At a dept h of about 50 m ( 160 fr) there is a feel ing of eu-
phor ia (not unlike that following a mart ini or two), and di vers ha ve been known
to offer their mouthpi eces to fish ! At higher parti al pressures, loss of coordination
and eventually coma may develop.
The mechani sm of action is not understood but may be related to the hi gh
fat.water solubilirv of N
, which is a general property of anesthet ic agent s. Othe r
gases, such as hel ium and hydrogen , can be used at much greater depths without
narcot ic effects.
We sawearlier that inhalation of 100% Oz at 1 atmosphere can damage the lung.
Another form of O
toxicity is st imulat ion of the eNS, leading to convulsions,
when the Poz cons iderably exceeds 760 mm Hg. The convulsions may be pre-
ceded by premoni tory symptoms such as nausea, ringing in the ears, and twitch...
ing of the face.
The likelihood of convul sions depends on the inspired P O I and the J uration
of exposure, and it is increased if the subject is exercising. At a Poz of 4 at1110;
spheres. convulsions frequent ly occur wit hin 30 minutes. For increasingly deep
dives, the Oz conc entration is progressively reduced to avoid toxic effect.s and
may eventually be less than 1% for a normal inspired R1z! The amateur scuba
diver should never fill his or her tanks with 0
because of the danger of a convul-
Decompression Sickness
• Caused by the formation of N
bubbles during ascent f rom a deep dive
• May result in pain (vbenos"! and neurological disturbances
• Can be prevented by a slow, staged ascent
• Treated by recompression in a chamber
• Incidence is reduced by breathi ng a helium-oxygen mixture
sion underwat er . However , pur e O
is somet imes used by th e military for shallow
Jives because a closed breath ing circuit wit h a CO
absor ber leaves no tell tal e
bubbles. The biochemical basis for the deleterious effects of a high Po , on the
CNS is not fully understood but is probabl y the inact ivation of certain enzymes,
especially deh vdropenascs conta in ing sulfhyd ryl groups.
Hyperbaric O
Increasing the arter ial POI to a very h igh level is useful in some clinical situat ions.
One issevere COpoison ing in whi ch most of the hemoglobin is bou nd to CO and
is th erefore una vailable to ca rry Oz. By raising the inspired POI to 3 atmosphe res
in special chambers, the amount of di ssolved O
in art erial blood can be inc reased
to about 6 ml/l OO ml (see Figure 6-1), and thus the needs of the t issues can he met
without funct ioning hemoglobin. Occasiona lly, an anemic crisis is managed in
this way. Hyperbaric Oz is also useful for treat ing gas gangrene because the or -
ganism cannot live in a high PO I environment . A hyperbar ic cha mber is also use-
ful for treat ing decompression sickness.
Fire and explosions are serious hazards of a 100% Oz atmosphe re, especially at
increased pressure. Forthi s reason, O
in a pressure chamber isgiven by mask, and
the chamber itself is filled with air.
Polluted Atmospheres'
Atmospheric pollut ion is an increasing problem in many count ries as the number
of motor veh icles and industr ies increas es. T he chief pollut ants arc various oxides
of nitrogen and sulfur, ozone, carhon monoxide, various hydrocarbons, and par-
ticulare matter. Of these, nitrogen oxides, hydrocarbons, and CO arc produced in
large quantities by the internal combustion engine, the sulfur oxides mainl y come
from fossil fuel power sta t ions, and ozone is chiefly formed in the at mosphere by
the ac t ion of sunlight on nitrogen oxides and hydrocarbons. The concentra t ion
of at mospheric poll utants is greatl y increased by a temperature inversion whi ch
preven ts th e normal escape of the warm surface air to the Li pper atmosphere.
Nitrogen oxides cause infl ammation of the upp er respiratory tract and eye ir-
rita tion, and they arc responsible for th e yellow haze of smog. Sulfur oxi des and
ozone also cause bronchi al inflammat ion, and ozone in high concent rations can
produce pulmonary ed ema. T he danger of CO is its propensity to t ie up
hemoglohin (see p. 80) , and cycl ic hydrocar bons are potent ially carcinogenic.
Both th ese po llutants exis t in tobacco smoke, which is inhaled in far hi gher
concentrati ons th an any other at mosp heric poll utant . There is evi dence that
some pollu tants act syn ergist ically, that is, t he ir co mbined act ions exceed the sum
of the ir individual act ions, hut more work is required in this area.
Many poll utants exist as a e r o s o L ~ , that is, very small part icles that remain sus-
pended in th e air. When an aerosol is inhaled, its fate depends on th e size of the
pan icles. Large parti cles are removed by impactionin the nose and pharynx. This
:j: For a more detailed account, Sl'C JB \Vest : Pulmonar)' PathoJ)hysiology- The Essenuais, ed
6. Baltimore, Lippincot t Williams & Wilkins, 2003.
means that the particl es are unable to tur n the corners rap idly because of their in-
ert ia, and th ey impi nge on the wet mucosa and are trapped. Med ium- sired r ani,
des deposit in small airways and elsewhere because of their weight. This is called
sedimentation and occurs especiall y where the flow velocit y is suddenly reduced
because of the enor mous increase in combined airway cross sect ion (Figure 1, 5).
For this reason, deposit ion is heavy in the termina l and respiratory bronchioles.
and th is region of a coal miner's lung shows a large dust concentrat ion. The small-
est part icl es (less than 0. 1 micron in diameter) reach the alveoli, where some de-
position occurs through diffusion to the walls. ~ 1 a n y small part icles are not de-
posited at all hut are exhaled with the next breath.
Once deposited, most of the part icles are removed by various cl earance mech-
an isms. Parti cles that deposit on bronch ial walls are swept up the mov ing stair,
case of mucus whi ch is propelled by cilia, and they are either swallowed or ex,
pectorated. However, rhe ci liary action can be paralyzed by inhaled irritants .
Part icles deposited in the al veoli are ch iefly engulfed hy mncrophagcs that leave
via the blood or lymphatics.
Liquid Breathing
It is possible for mammals to survive for some hours breathing liquid inst ead of air.
Thi s was first shown with mice in saline in which th e O
concent ration was in-
creased by exposure to 100% O
at 8 atmospheres pressure. Subsequently, mice.
Ta ts, and dogs have survived a period of breath ing fluorocarbon exposed to pure
at I atmosphere. This liquid has a high solubility for bot h 0 , and CO
, The
an imals successfully returned to air breath ing.
Because liquids have a much hi gher densit y and viscosity than air, the work of
breathing is enormo usly increased. However, adequate oxygenation of the urte-
rial blood can be obtained if th e inspired concent rat ion is raised sufficiently. In,
terestinglv, a serious problem is eliminat ing CO
• \Ve Sa\V earlier that diffusion
with in the airways is chiefly responsihle for the gas exchange tha t occurs bet ween
the alveoli and the terminal or respirat or y bronch ioles, where bulk or convect ive
flow takes over. Because the diffusion rates of gases in liquid are many orders of
magnitude slower than in th e gas phase, this means that a large partial pressure
difference for CO
between alveoli and te rmin al bronchioles must be ma intained.
An imals breathing liquid, th erefore, commonly develop CO
retention and aci-
dosis. No te th at the diffusion pressure of O
can always be raised by increasing the
inspired PO I ' hut thi s opt ion is not ava ilable to help eliminate CO
, Liquid
• brea th ing has been proposed as a possible way of ventilat ing infants with t he res-
piratorv distress syndro me caused by lack of surfactant. The aim is to tide them
over the danger per iod unt il the surfactant system matures.
Perinatal Respiration
Placental Gas Exchange
During fetal life, gas exchange takes place through th e placenta. Its ci rculation is
in parallel with that of the peripheral tissues of the fetus (Figure 9-5) unlike the
Respiratory System Under Stress 149
situation in the adult in which the pulmonary circulat ion is in series with the svs-
temi c circulat ion. Maternal blood enters the placenta from the uteri ne arteries
and surges into small spaces called intervillous sinusoids which funct ion like the
alveoli in the adult. Fetal blood from the aorta is supplied to capill ary loops that
protrude into the intervillous spaces. Gas exchange occurs across the blood, blood
barrier, approximately 3.5 urn thick.
This arrangement is much less efficient for gas exchange than in the adult
lung. Maternal blood apparen tly swirls around the sinusoids somewhat haphaz-
ardly, and there are probably large differences of Po, within these blood spaces.
Contrast this situat ion with the air-filled alveoli in whic h rapid gaseous diffusion
st irs up the alveolar contents. The result is that the P0 2 of th e fetal blood leaving
the placenta is only about 30 mm Hg (Figure 9-5) .
This blood mixes with venous blood draining from the fetal tissues and reaches
the right atr ium (RA) via the inferior vena cava (l v e ). Because of streaming
with in the right atr ium, most of this blood then flows directl y into the left atrium
ivc 22
Figure 9-5. Blood circ ulation in t he human fetus. The numbers show the app rox
imate P02of the blood in mm Hg. See text f or details.
(LA) through the ope n foramen ovale (FO) and rhus is distributed via the as-
cending aort a to the brain and heart. Less well oxygenated blood returning to the
right atrium via the superior vena cava (SVC) finds its way to the right ventricle
(RY), hut only a small port ion reaches th e lungs. Most is shunted to the aorta
(Au) through the ductus arteriosus (DA). The net result of thi s complex ar-
rangc menr is that the hest oxygenated blood reaches the brai n and heart , and the
non-gas-exchanging lungs receive only about 15% of the cardiac output. Note
that the arterial Po z in th e descending aor ta is onl y about 22 mm Hg.
To summarize th e three most important di fferences between the fetal and
adult circulati ons:
1. The pl acenta is in parallel wit h t he circulat ion to the t issues whereas the
lung is in series in the adult.
2. The ductus arteriosus shunts most of the blood from the pulmonary artery
to the descending aorta.
3. Str eaming within the right atr ium means that the oxygenated blood from
the placenta is preferent ially del ivered to the left at rium through the fora-
men ova le and therefore via the aorta to the brain.
The First Breath
The emergence of a baby int o the outside world is perhaps the most cataclysmic
event of his or her life. The baby is suddenly bombarded with a variety of ex-
ternal st imuli. In addit ion, the process of birth int er feres with placental gas ex-
change with resultin g hypoxemia and hypercapni a. Finally, the sensit ivity of
the chernoreceptors apparently increases drama tically at birt h, although the
mechani sm is unknown. As a consequence of all these changes, the baby makes
the first gasp.
The feral lung is nor collapsed bur is inflated with liquid ro about 40% of to-
tal lung capaci ty. This fluid is conti nuously secreted by alveolar cells during fe-
tal life and has a low pH. Some of it is squeezed out as the infant moves through
the birt h canal, bur the remaind er has an import ant role in the subsequent in-
flation of the lung. As air enters the lung, large surface tension forces have to
be overcome. Because the larger the radius of curvature, the lower the pressures
(see Figure 7 ~ 4 ) , th is preinflation reduces the pressures requi red. Nevertheless,
the intrapleural pres. sure during the first breath may fall to - 40 cm water before
any air enters the tung, and peak pressures as low as - 100 em water during the
first few breaths have been recorded. These very large transient pressures are
partly caused by the high viscosit y of the lung liquid compared with air. The fe-
tus makes very small, rapid breathi ng movements in the uterus over a consider-
able per iod before bi rth.
Expansion of the lung is very uneven at first. However, pulmonary surfactant,
which is formed rela tively late in fetal life, is ava ilable to stabilize open alveoli,
and the lung liquid is removed by the lvmpha t ics and capillar ies. Wir hin a few
moments, the functional residual capacit y has almost reached its normal value
and an adequate gas exchanging surface has been established. However, it is sev-
eral days before uniform vent ilat ion is achieved.
Changes at or Shortly After Birth
• Baby makes strong inspiratory efforts and takes its first breath
• Large fall in pulmonary vascular resistance
• Ductus arteriosus closes, as does the foramen ovate
• Lung liquid is removed by lymphatics and capillaries
Ci rculat ory Changes
A dramatic fall in pulmo nary vascular resistance foll ows the first few breaths. In
the fetus, the pulmonary art eries are exposed to the full systemic blood pressure
via the ductus art eriosus, and th eir wall s are very muscular. As a result, the resis-
tanee of the pu lmonary circulation is exquis itely sensitive to such vasoconstrictor
agents as hypoxemia, acidosis, and sero tonin and to such vasodilators as acetyl-
choli ne. Several factors account for th e fall in pul monary vasc ular resistanc e
at birth , including the abrupt rise in alveolar P O l that abolishes the hypoxic vaso-
constriction and the increased volume of the lung tha t widens the ca liber of the
extra-alveo lar vessels (see Figure 4 ~ 2 ) .
With the resulting increase in pulmonary blood flow, left atrial pressure rises
and the flap-l ike foramen ovale quickly closes. A rise in aortic pressure result ing
from the loss of the para llel umbilical circulation also increases left atr ial pressure .
In addition, right atrial pressure falls as the umbil ical flow ceases. The ductus
arte riosus constricts a few minutes later in response to the di rect action of th e in-
creased P
0 2
on its smooth muscl e. In addi t ion, this cons tric tion is aided by alter-
at ions in the levels of local and circulat ing prostaglandins. Flow through the due-
tus arteriosus soon reverses as the resistance of the pul monary circulat ion falls.
For each question, choose t he one best answer.
1. All of t he fol lowing st atements about exercise are true EXCEPT:
A. It can increase the oxygen consumption more t han te nfold compared
with rest.
B. The measured respiratory exchange rati o may exceed 1.0.
C. Vent ilat ion Increases much more than cardiac output.
D. At high levels of exercise blood lactat e concentrations may rapidly
E. The change in vent ilation on exercise can be explained by the fall in arte-
rial pH.
2. Features of acclimat izat ion to high alt itude include all of t he fo llowing
A. Hyperventilation.
B. Polycythemia.
C. Rightwa rd shift of t he O
dissociat ion curve at extreme alt it udes .
D. Increase in t he number of capillaries per unit volume in skeletal muscle.
E. Changes in oxidat ive enzymes inside muscle cells.
3. If a small airway in a lung is blocked by mucus. t he lung distal to t his may
become atelect at ic. Which of t he following stat ement s is FALSE?
A. Atel ect asis occurs f aster if the person is breathing oxygen rat her
t han air.
B. The sum of the gas part ial pressures in mixed venous bl ood is less t han
in arterial blood.
c. The blood f low to the atelectati c region will fall.
D. The same mechanism explains t he absorpt ion of a spontaneous pneu-
E. The elast ic properti es of t he lung st rongly resist atelectas is.
4. Helium-oxygen mi xtures rat her than nit rogen-oxygen mixtures (with t he
same oxygen conce nt ratio n) are preferable for very deep divi ng because all
of t he f ollowing are reduced EXCEPT:
A. Risk of decompression sickness.
B. Work of breathing .
C. Airway resistance.
D. Risk of O
t oxicity.
E. Risk of inert gas narcosi s.
5. The absence of gravity during spacef light alters all of t he following EXCEPT:
A Distr ibuti on of pulmonary blood flow .
B. Distribution of ventilation.
C. Deposit ion of inhaled aerosol part icles.
D. Thoracic blood volume.
E. Wo rk of breat hing.
6. Which of the following increases by the largest percentage at max imal exer-
cise compared wit h rest ?
A Heart rate.
B. Alveol ar ventila tion.
C. P
of mix ed venous blood.
D. Cardiac out put.
E. Tidal volume.
7. The t ransition fro m placental t o pulmonary gas exchange is accompanied by
all of t he following EXCEPT:
A. Increased arterial POz'
B. Fall of pul monary vascular resistance.
C. Closure of the duct us arteriosus.
D. Reversal of blood f low t hrough the foramen ovale.
E. Strong respi ratory efforts.
Tests of Pulmonary Function
How Respiratory Physiology Is Applied to Measure
Lung Function'
Vent ilat ion
Forced Expi ration
Lung Volumes
Blood Flow
Ve nt ilation-Perfusion
Topographical Distribution of
Ventilation and Perfusion
Inequality of Ventilat ion
Inequality of Venti lation
Perfusion Ratios
Blood Gases and pH
Mechanics of Breathing
Lung Compliance
Airway Resistance
Closing Volume
Control of Ventilation
Perspective on Tests of
Pulmonary Function
This final chapter deals with pulmonaryfunction testing which is animportant
practical application of respiratory physiologyin theclinic. First we look at the
forced expiration. a very simple but nevertheless very useful test. Then there
are sections on ventilation-perfusion relationships. bloodgases, lungmechan-
ics, control of ventilation and the role of exercise. The chapter concludes by
emphasizing that it is moreimportant to understandtheprinciplesof respiratory
physiology contained in Chapters 1-9 thanto concentrateonthedetails of pul-
* This chapter is only a brief introducti on to pulmonary functi on tests. A more derailed de-
scription can he found in ]B West: Pulmonary Pathophysiology-The Essentials, cd 6.
Balt imore, Lippincott, Williams & Wi lkins, 2003 .
: ~
An important practical app lication of respirator y phys iology is t he test ing of pul-
monary funct ion. These tests are useful in a va riety of sett ings. The most impor-
tant is the hospital pulmonary func tion laboratory Of, on a small scale, the physi-
ci an 's office, wher e these tests h elp in t he diagn osis and the ma nagement of
pat ients with pulmonary or cardiac di seases. In addition, they may be valuable in
decidi ng whe ther a pat ien t is fit enough for surgery_ Another use is the evaluation
of disabilit y for t he purp oses of insurance and wor ker's co mpe nsat ion. Again,
some of the simpler tests are employed in epidemiological surveys to assess ind us-
tr ial h azards or to document the prevalence of disease in the community.
The rol e of pulmonary funct ion te sts should be kept in perspect ive . They are
rarely a key factor in makin g a definiti ve di agnosis in a pat ient wit h lung disease.
Rat her, the various pa t terns of impaired funct ion overlap disease entities. Wh ile
the te sts are often val uable for following the progress of a patient wit h chron ic
pu lmona ry disease and assessing the results of treatment, it is generally far more
important for the medical student (or physici an) to understa nd the pr inciples of
how the lung wor ks (Chapters 1 through 9) than to concentrate only on lung
funct ion tests.
Forced Expiration
A very useful and simple test of pulmonary func t ion is the measur ement of a sin-
gle forced expiration, Figur e 1O ~ 1 shows t he spirometer record obtai ned when a
subject inspires maximally and t hen exhales as hard and as completely as he or
she can, The vo lume exhaled in the first second is called the forced expirato ry
volume, or FEY1.0, and t he tot al vol ume exhaled is the forced vita l capacity, or
FVC (t h is is often slightly less than t he vital ca pacity measured on a slow exha-
lat ion as in Figure 2-2). Normally, the FEVl.
is about 80% of the FVC.
A. Normal B. Obst ructive C. Restrictive
~ \ E ;
~ I I
FVC .. j.
11sec] 11sec ]
FEV= 4.0
FVC= 5.0
FEV=1 .3
FVC = 3.1
FEV = 2.8
FVC= 3.1
Figure 10-1. Measure ment of f or ced exp i rat ory volume (FEV1.Q) and forced vit al
capacity (FVC).
o 98 765432
Lung volume (I)
o 6 5 4 3 2
Lung volume (I)
( Airway collapse
", Effort inde penden t



2 u,
Figure 10-2. Flow vo lume curve obtai ned by recor din g flow rat e agai nst volume
during a fo rced expirat ion f rom maximum i nspi ration. The fig ure shows absolute
lung vo lumes, al though these cannot be measured f rom single expirations.
In disease, ( \\-'0 general pattern s can be dist inguished. In restrictive diseases such
as pulmonary fibrosis, both FEY and FYC ate red uced, but cha racterist ically the
FEYl.o/FVC% is nor mal or increased. In obstructive diseases such as hronc hial
asthma, the FEV1.0 is reduced much more than the FVC, giving a low
FEVjFVC%. Frequently, mi xed restr icti ve and obstr uctive patterns are seen.
A rel ated measurement is the farced expiratoryflowrate, or FEF
'X> ' wh ich is
the average flow rate measured over the middle half of the expirat ion. Ge nerally,
th is is closel y related to the FEY1.0 , although occasionally it is reduced when the
is normal. Somet imes other indices are also measured from the forced ex-
pirati on curve.
A useful way of looking at forced expirat ions is with j1ow-volume curves (see
Figure 16). Figure reminds us that after a relati vely small amoun t of gas has
been exhaled, flow is limi ted byairway compression and is dete nn ined by the elas-
tic recoil force of the lung and the resistance of the airways upstream of the col-
lapse poi nt. In restrictive diseases, the maximum flow rate is reduced, as is the to-
tal volume exh aled. However , if flow is related to the absolute lung volume (that
is, including the residual volume which cannot be measured from a single expira-
tion ), the flow rat e is often abnor mally hi gh during the latt er part of expirat ion
because of the increased lung recoil (Figure 10-213). By contrast, in obstructive dis-
eases the flow rat e is very low in relat ion to lun g volume, and a scooped-out ap-
pearance is often seen following the point of maximu m flow.
What is the sign ificance of these measurements of forced expirat ions? The
FYe may be reduced at its top or bottom end (see Figure In re5tTictit'e
Forced Expiration Test
• Measures the FEVand the FVC
• Simple to do and often informative
• Distinguishes between obstructive and restrict ive disease
di seases, inspirat ion is limited by the reduced compliance of the lung or chest
wall, or weakness of th e inspirat ion muscles. In obstrucrit!e disease, the rotal lung
capaci ty is typically abnormally large, but expirat ion ends prematurely. The rea-
son for this is earl y airway closure brought about by increased smooth muscle tone
of the bron chi, as in ast hma, or loss of radial tracti on from surrounding
parenchyma, as in emphysema. Othe r causes include edema of the bronch ial
walls, or secret ions within the airways.
The FEYl.o (or FEF
%) is reduced by an increase in airway resistance or a
reduction in elastic recoil of the lung. It is remarkably independent of expiratory
effort. The reason for th is is the dynami c compression of airways, which was dis-
cussed earlier (see Figure 7~ 18). This mechanism explains why the flow rate is in-
dependent of the resistance of the airways downstream of th e collapse poin t but
is determined by the elast ic recoil pressure of the lung and the resistance of the
airways upstream of the collapse point. The location of the collapse point is in the
large airways, at least init ially. Thus, both the increase in airway resistance and
the reduct ion of lung elastic recoil pressure can he important factors in the re-
duct ion of the FEYLO, as, for example, in pulmonary emphysema.
Lung Volumes
The determi nati on of lung volumes by spirometry and the measurement of func-
tiona l residual capacity (FRC) by helium diluti on and body plethysmography
were discussed earlier (see Figures 2-2 through 2-4). The FRC can also be found
hy ha ving the subject breathe 100% 0 , for several minutes and washing all the
Nz out of the subject 's lung.
Suppose that the lung volume is VI and that the total volume of gas exha leJ
over 7 minutes is Vz and th at its concent rat ion of N
is C
- We know that th e
concen tration ofN
in the lung before washout was 80%, and we can measure the
concentrat ion left in the lung bysampling end-expired gas with an N
meter at
the lips. Call this concentrat ion C'}. Then, assuming no net change in th e amount
"fN" we can write VI X 80 = (VI X e ,l + (V, X C,l. Thus, VI can he derived.
A disadvantage of thi s method is that the concentration of nitrogen in the gas
collected over 7 minutes is very low, and a small error in its measurement leads to
a larger error in calculated lung volume. In addit ion, some of the N
that is
washed out comes from body tissues, and this should he allowed for. This method,
like t he helium dilut ion techniq ue, measures only vent ilated lung volume,
whereas, as we saw on p. 16, th e body plethysmograph method includes gas
trapped behind closed airways,
The measurement of anatomic dead space by Fowler's method was described
earlier (see Figure 2-6).
The princ iples of the measurement of the diffusing capacity for carbon monox ide
hy the single breath method were discussed on p. 31. The diffusing capacity for
is very difficult to measure, and it is only done as a research procedure.
Blood Flow
The measurement of total pulmonary blood flow by the Fick pri nci ple and by the
indicator dilut ion method was alluded to on p. 42.
Ventilation-Perfusion Relationships
Topographical Distribution of Ventilation and Perfusion
Regional differen ces of vent ilat ion and blood flow can be measured using ra-
dioact ive xenon, as briefly described earl ier (see Figures 2-7 and 4-7).
Inequality of Ventilation
This can he measured by single breath and multi ple breath methods. The single
breathmethod is very similar to that described by Fowler for measur ing anatomic
dead space (Figure 2-6) . There we saw that if the N
concentration at the lips is
measured following a single breath of Oa. the N
concent rat ion of the expired
alveolar gas is almost uniform, giving a nearl y flat "alveolar plat eau." This reflects
the approximately uni form dilut ion of th e alveolar gas by the inspired Oz. Bycon-
t rust, in pat ients with lung disease, the alveolar Nz concentrat ion cont inues to
rise during expiration. This is caused by the uneven diluti on of the alveolar N
inspired O
The reason why the concentration rises is that the poorly vent ilated alveoli
(those in which the N, has been diluted least) always empt y last, presumably be-
cause they have long t ime constants (Figures and In practice, the
change in N
percentage concent rat ion between 750 and 1250 ml of expired vol-
ume is often used as an index of uneven vent ilati on. This is a simple, quick, and
useful test.
The multiple breath method is based on the rate of washout of N
as shown in
Figure The subject is connected to a source of 100% Oz, and a fast-re-
spondi ng N
meter samples gas at th e lips. If the vent ilat ion of the lung were uni -
form, the Nz concentrat ion would be reduced by the same fraction with each
breath. For example, if the tidal volume (excluding dead space) were equal to the
FRC, the Nz concentrat ion would halve with each breat h. In general, the N
concent rat ion is FRC/lFRC + (V
- Vn)J times that of the previous breath,
where V
and VI)are the t idal volume and anatomic dead space, respect ively. Be-
cause the Nz is reduced by the same fract ion with each breath, the plot of log N2
concent rat ion against breath number would be a straight line (see Figure 1 3) if
the lung behaved as a single, uniformly vent ilated compartment. This is very
nearl y the case in norma] subjects.
In pati en ts wit h lung disease, however, th e nonuniform vent ilat ion result s
in a curved plot because different lung units have their N
diluted at different
rates. Thus, fast vent ilated ahveoli cause a rapid initial fall in Na. whereas slow
vent ilated spaces are responsible for the long tail of the washout (see Figure
10-] ).
80 <' 80
meter "-
.g m '"

- u 8 ...
:i340 V! .
U OJ • •
6 g
u _
0.8 ...
:·vFast space
, #
-', '"'"
8 ,--_ "..
\ \ -
" Sl ow .. \
... space
o 1 234 5 o 10 20 30 40 0 10 20 30 40
Number of breaths Number of breaths Number of breaths
Figure 10-3. N
washout obtaine d when a subj ect breathes 100% O
_ Nor mal
lu ngs gi ve an al most li near pl ot of N
concentration against number of breat hs on
semlloqartt hmlc paper, but this plot is nonlinear when uneven vent i lation is pre-
Inequality of Ventilation-Perfusion Ratios
One way of assessing the mismatch of vent ilation and blood flow within the dis-
eased lung is that introduced by Riley. This is based on measuremen ts of P0 2 and
! in arterial blood and expired gas (the princi ples were briefly described in
Chapt er S). In practice, expired gas and arterial blood are collected simulrane-
ously from the patient, and various indices of venti lation-perfusion inequali ty are
One useful measurement is the PO l difference. We saw in Figure
11 how thi s develops because of regional differences ofgas exchange in th e nor'
mal lung. Figure l OA is an diagram th at allows us to examine th is de-
velopment more closely. First , suppose that there is no venti lat ion- perfusion in-
equality and that all the lung units are represented by a single point (0 on the
ventilat ion-perfusion line. This is known as the "ideal" point. Now as venula-
non-perfusion inequality devel ops, the lung units begin to spread away from i to-
ward both v(low venrilarion-perfusion rati os) and I (high vent ilation-perfusion
rati os) (compar e Figure 5-7) . When this happens, th e mixed capi llary blood (a}
and mixed alveolar gas (A) also diverge from i. They do so along lines i to vand
i to I, which represent a constant respirator y exchange ratio (C0
output/02 up-
take), 3 5 this is det ermined by the metabolism of the body tissues."
The horizo ntal distance between A and a represents th e (mixed ) aft'ealnr,
arterial O
difference. In practice, th is can only be measured easily if vent ilat ion i.....
essentially uniform but blood flow is uneven, because only then can a reprcsen-
t In this necessaril y simplified descri pti on, some det ails are omitted. For exa mple, the
mixed venous point alters when ventilarion -pertusion inequali t y de velops.
where Qrs/Qr refers to th e rat io of the physiologic shunt to total flow. The 0, con-
centrat ion of ideal blood is calculated from the ideal Pa zand O
dissociation curve.
Figure 10-4. 0 2-C0 2di ag ram showing t he ideal poi nt (i), that is, th e hypothet ical
composit ion of alveo lar gas and end-ca pillary blood when no ventilation-perfu-
sion i nequality is present . As i nequality develops. the art er ial (a) and alveolar (Al
poi nts diverge along t hei r respect ive R (respira tory exchange rat io) li nes. The
mi xed alv eol ar-art eria l P02 differen ce is th e horizont al dist ance between t he
Cio, - Cao,
o z
- evo
Low VA/a
" .
0> 40

I Blood A
E line

40 60 80 100 120 140
Paz mm Hg
rat tvc sample of mixed alveolar gas be obtained. This is somet imes the case in pul -
monary embolism. More frequently, the POl difference between ideal alveolar gas
and arterial blood is calculated-the (ideal) al"eolar-arterial 0
difference. The
ideal alveolar Po zcan be calculated from the alveolar equation which rel ates
the Pozof any lung unit to the composition of the inspired gas, the respirato ry ex-
change ratio, and the P
a Jz
of the uni t. In the case of ideal alveoli , the rCX)z is
taken to be the same as art er ial blood because the line along which point i moves
is so nearly horizontal. Note that thi s alveolar-arterial PO l difference is caused by
uni ts between i and Y, that is, those with low ventilati on-perfusion ratios.
Two more indices of vent ilat ion-perfusion inequality are frequently der ived.
One is /)hysiologic shunt (al so called venousadmixture). For thi s we pretend that all
of the leftward movement of the arterial point (a ) away from the ideal point (i)
(that is, the hypoxemia) is caused by the addition of mixed venous b100d m to
ideal blood (0. This is not so fancifu l as it first seems, because units with very low
vent ilat ion-perfusion rati os put out blood that has essentia lly the same composi-
t ion as mixed venous blood (see Figures 5-6 and 5-7) . In pract ice, the shunt equa-
t ion (see Figure 5-3) is used in the following form:
160 Chapter 10
The other index is alveolar dead spece. Here we pretend that all of the movement
of the alveolar point (A ) away from the ideal point (i ) is caused by the addi tion of
inspired gas ill to ideal gas. Aga in, thi s is not such an outrageous notion as it may
first appear because units wit h very high vent ilation-perfusion rat ios behave very
much like point I. After all, a unit with an infinitely hi gh vent ilat ion-perfusion ra-
t io contai ns gas that has the same composit ion as inspired air (see Figures 5.6 and
5.7) . The Bohr equation for dead space (see p. 19) is used in the following form:
Pico! - PAa )!
where A refers to expired alveolar gas. The result is called all'eolardeadspace to
distinguish it from the anatomic dead space, that is, the volume of th e conduct-
ing airways. Because expired alveolar gas is often difficult to collect without
contamination by th e anatomic dead space, the mixed expired CO
is often
measured. The result is called the physiologic deadspace , which includes compo-
nents from the alveolar dead space and anatomic dead space. Because the P
of ideal gas is very close to that of arterial blood (see Figure 10-4) , th e equat ion
for physiologic dead space is
P"co, - PEco,
The normal value for physiologic dead space is about 30% of the tidal volume at
rest and less on exercise, and it consists almost completely of anatomic dead
space. In lung disease it may increase to 50% or more due to the presence of ven-
nl an on-perfuston inequalit y.
Blood Gases and pH
POl' Pco ., and pH are easily measured in blood samples with blood gas elect rodes.
A glass electrode is used to measure the plI of whole blood. The PCX), elect rode
is, in effect, a tiny pH meter in whic h a bicarbonate buffer solut ion is separated
from the blood sample by a thin membrane. When carbon dioxide diffuses across
the membrane from the blood, the pH of the buffer changes in accordance with
th e Henderson-Hasselbalch relat ionship. The pH met er then reads out the Peol"
The 0 , electrode is a polarograph, that is, a device which , when supplied with a
suitable voltage, gives a minute current that is proport ional to the amount of dis-
solved O
. In practi ce, all thr ee electrodes are arranged to give their out puts on
th e same met er byappropriate switching, and a complete analysis on a blood sam-
pie can be done in a few minut es.
We saw in Chapter 5 that there are four causes of lowarterial Pozor hypoxemia:
(I ) hypovent ilati on, (2) diffusion impairment, (3) shunt, and (4) ventilat ion-
perfusion inequality.
In distinguishin g between these causes keep in mind that hvpovent ilat ion is
always associated with a raised arterial P
and tha t only when a shunt is present
does t he arterial POz fail to rise to the expected level when 100% O
is udminis-
e at
ml arion is
- i ~ r resent
1j adminls-
tcred. In diseased lungs. imp air ed diffusion is always accompanied byve nt ilation-
perfu sion inequality, and, ind eed, it is usuall y impossibl e to det erm ine how much
of th e hypoxemia is att ribu table to defective diffusion .
There are two causes of an inc reased art erial Peol : (1) hvpovennlanon. and
(2) vent ilat ion- perfusion ine qua lit y. The latter does not always cause CO
rent ion because any tende ncy for the arte rial PeX)l to rise signals th e respiratory
center via the chemoreceptors to increase ventilat ion and thus hold the P
down . However, in the absence of this increased ventilat ion, the P
must rise.
Changes in the blood gases in different types of hypoxemi a are summarized in
Tahle 6.1.
The assessment of the acid-base stat us of the bl ood was discus sed on pp.
Mechanics of Breathing
Lung Compliance
Compliance is de fined as the volume cha nge per uni t ofpressure cha nge across th e
lung. To obta in th is, we need to kn ow intrapleural pressur e. In practi ce, esophageal
pressure is measured by having the subject swallow a small balloon on th e end of
a cathet er. Esophageal pressure is not identical to intrapleural pressure but reflects
its pressure changes fairly well. The measurement is not reliable in supine subjects
beca use of inte rference by th e weight of the med iastinal struc tures.
A simple way of measuring compliance is to have the subject breathe out from
total lung capaci ty into a spirometer in steps of, say, 500 ml and measure hi s or her
esophageal pressure simultaneously. The glott is should be open, and the lung
sho uld be allowed to stabilize for a few seconds after eac h step. In this way, a
pressure-volume curve simil ar to the upper line in Figure 7~ 3 is obtained. The
whol e curve is the most informative way of reporting the elast ic be havior of the
lung. Indices of the share of the cur ve can be derived. Not ice that the compii-
ancc, which is the slope of the curve, will var y depending on what lung vol ume
is used. It is convent iona l to report th e slope over the lit er above FRC measured
during deflat ion . Even so, the measur ement is not ve ry repeat able.
Lung compliance can also be measured dur ing resting breathing, as shown in
Figure 7~ 13. Here we make use of the fact that at no-flow points (end of inspi ra-
ti on or expirat ion), the intrapleural pressure reflec ts only th e elasti c recoi l forc es
and not those assoc iated with airflow. Thus, the volume difference di vided by the
pressure difference at these points is the compliance.
This method is not valid in patie nts with airway di sease because the varia-
ti on in time constants throughout the lung means that flow st ill exists within
th e lung when it ha s ceased at the mouth. Figure 1 0 ~ 5 shows that if we conside r
a lung region tha t has a partially obstructed ai rwa y, it will always lag behi nd the
rest of rhe lung (compare Figure 7-19) . In fact, it may cont inue to fill when the
rest of the lung has begun to emp ty, with the result that gas moves into it from
adjoining long units-so called pendelluft (swinging air). As the breathi ng fre-
que ncy is increased, the proportion of the t ida l vo lume that goe s to th is par-
t ially obstructed region beco mes smaller and smaller. Thus, less and less of t he
Figure 10-5. Effect s of un eve n time constants on ventil at ion. Compartment 2 has
a partiall y obst ruct ed air wa y and, t herefore, a long ti me constant (co mpare Figure
7-19). Duri ng inspirati on (A), ga s is slow to ent er it , and it t he refore cont i nues t o
f ill after t he rest of t he lung (1) has sto pped movi ng (6). Indeed at t he begi nni ng
of t he expir ation Ie). t he abnormal region (2) may st ill be inhali ng w hi le th e rest
of the lung has begun to exhale. In D, both regions are exhaling but compartment
2 lags behind co mpartment 1. At higher fr equencies, th e tidal vo lume to th e ab-
normal region becomes progressively smaller.
lung is partici pat ing in the tidal volume changes, and therefore the lung appears
to become less compliant.
Airway Resistance
This is the pressure difference between the alveoli and the mouth per unit of air'
flow (Figure 7-12). It can be measured in a body plethysmograph (Figure 10-6) .
Before inspirat ion (A) , the box pressure is atmosphe ric. At the onse t of inspi-
ration, the pressure in the alveoli falls as the alveolar gas expands by a volume
~ V. This compresses the gas in the box and from its change in pressure av can
be calculated (compare Figure 2-4). If lung volume is known, f!,. V can be con-
vert ed into alveolar pressure using Boyle' s law. Flow is measured simultaneously,
and thus airway resistance is obtained. The measurement is made during expira-
tion in the same way. Lung volume is determined as described in Figure 2-4.
Airway resistance can also be measured during normal breathing from an in,
rrapleural pressure record as obtai ned with an esophageal ball oon (see Figure
7,13). However, in th is case, tissue viscous resistance is included as well (see
p. 116). Intrapleural pressure reflects two sets of forces, those opposing the elast ic
Tests of Pulmonary Function 163
recoil of the lung and th ose overcoming resist ance to air and t issue flow. It is
sible to subtract the pressure caused by the recoil forces during quiet breathing be-
cause th is is proportional to lung volume (if compliance is constant ). T he sub-
traction is done with an electri cal circuit. We are then left with a plot of pressure
against flow whi ch gives (a irway + t issue ) resist ance. This method is not sati s-
fact ory in lungs with seve re airway disease because the uneven time constants Pre-
vent all regions from moving together (see Figure
Closing Volume
Earl y disease in small airways ca n be sought byusing the single brea th N
(see Figure and thus exploiting the topographical differences of ventilati on
(see Figures 7-8 and 7-9). Suppose a subject takes a vital capacity breath of 100%
Oz and during the subsequent exhalat ion the Nz concentrat ion at t he lips is mea,
sured (Figure Four phases can be recognized.
First , pure dead space is exha led ( I ) followed by a mixture of dead space and
alveolar gas (2), and then pur e alveol ar gas (3). Toward the end of expiration ,
an abrupt inc rease in N
concen trat ion is seen (4 ). Thi s signa ls closure of ai r-
ways at the base of the lung (see Figur e 7 and is ca used hy prefer en tial
tying of the apex, wh ich has a relatively h igh concen tration of N
The rea son
for the h igher N
at the apex is that during a vital capaci ty breat h of Oz, th is
region expands less (see Figure and, therefor e, the N
there is less dil uted
with Oz. T hus, the volume of the lung at wh ich dependent airways begin to
clo se ca n be read off the tr acing.
In young normal subj ects, the closing volume is about 10% of the vital capac-
ity (Ve). It increases steadily with age and is equal to about 40% of the ve, that
is the FRe , at about th e age of 65 years . Relat ively sma ll amoun ts of disease in the
small airways appare ntly increase the closing volume. Somet imes the closingcz-
pacity is repor ted. Th is is the closing volume plus the residual volume.
' "
During During
inspiration expiration
Figure 10-6. Measurement of airway resist ance wit h t he body pleth ysmogr aph.
Durin g i nspir ati on, th e alveo lar gas is expanded, and box pressure t heref ore rises.
From t hi s, alveo lar pressure can be calcula ted. The diff erence between alveol ar
and mout h pressure, di vided by fl ow, gives ai rway resista nce (see text ).
Control of Ventilation
4 3 2
Closing I
volume :
5 4 3 2 0
Lung volume (I)
_ - - - VC - - - - - - - + l ~
~ .
Addit ional informati on about pulmonary funct ion can often be obtained if tests
are made when the subject exercises. As discussed at the beginning of Cha pter 9,
the rest ing lung has enormous reserves; its ventilat ion, blood flow, O
and CO
transfer. and diffusing capacity can be increased severalfold on exercise. Pre-
quently, patients with early disease have pulmonary function tests that are within
normal limit s at rest , but abnormaliti es are revealed when the respiratory system
is stressed by exercise.
Met hods of providin g controlled exercise include the treadmill and bicycle er...
gometer. Measurements most often made on exercise include total ventilat ion,
pulse rat e, O
uptake, CO
outpu t, respiratory exchange rat io, arterial blood
gases, and the diffusing capacity of the lung for carbon monoxide.
Figur e 10-7. Measu rement of t he clo si ng vo l ume. If a vit al capacity i nspi rat ion of
100% O
is followed by a f ull expi rat ion, fo ur phases in t he N
concent rat i on mea-
sured at t he lips can be recognized (see text). Th e last is caused by pre fer ent ial
emptyi ng of th e apex of t he lung aft er t he lower zone ai rways have cl osed.
The responsiveness of the chemorece ptors and respiratory cent er to CO
be measured by having the subject rebrearhe into a rubber bag, as discussed on
p. 129. We saw tha t the alveolar POz also affects ventilat ion so that if th e rc-
sponsc to CO
alone is requi red. th e inspired POl should be kept above 200 mm
Hg to avoid any hypoxic drive. The vent ilatory response to hypoxia can be
measured in a similar way if th e subject rebreathes from a bag with u low P Ol
but constant P COl '
Perspective on Tests of Pulmonary Function
In th is chapter, we have touched on some of the lung function tests that are
present ly available. In conclusion, it should be emphasized that not all these tests
are commo nly used in a hospital pulmonary funct ion laboratory. O nly a few can
he used in a doctor's office or on an epidemiological survey.
The most useful and simple test in the clinical sett ing is the forced expiration.
It does not matter much wh ich indices are de rived from this test , but the FEY1.0
and FVC are very frequently reported. Ne xt, the ability to measure arterial blood
gases is essent ial if pat ients wit h respi ratory failure are managed and is valuable in
any case. After these, the relati ve import ance of tests becomes more a matt er of
personal preference, but a well-equipped pulmonary function laboratory would be
able to measure lung volumes, inequality of vent ilation , alveolar-art erial Pozdif-
ference, physiologic dead space and shunt, di ffusing capaci ty for carbon monox-
ide, airway resistance, lung compliance, vent ilatory response to CO
and. hypoxia,
and the patient 's response to exercise. In large laborator ies, more specialized mea-
surements such as the topographi cal distribution of vent ilat ion and blood flow
would be available.
For each question, choose the one best answer.
1. Which of the following statements about the 1 second forced expiratory vol-
ume is FALSE?
A. It can be used t o assess the eff icacy of bronchooilators.
B. It is reduced by dynamic compression of the airways.
C. It is reduced in pat ient s with chronic obstructive pulmonary disease but
not pulmonary fibrosis.
D. It is reduced in patients wi th ast hma.
E. The t est is easy t o perform.
2. All of the followi ng may reduce the FEV1 in a pat ient with chronic obstr uctive
pulmonary disease EXCEPT:
A. Hypertrophy of the diaphragm.
B. Excessive secretions in the airways.
C. Reduction in the number of small airways.
D. Loss of radial traction on the airways.
E. Loss of elastic recoil of the lung.
3. All of the following statements are true of the Si ngle breath nitrogen test for
uneven ventilation EXCEPT:
A. The slope of the alveolar plat eau is increased in chronic bronchit is.
B. The slope occurs because poorly ventil ated units empty later in expira-
t ion than well-ventilated unit s.
C. The last exhaled gas comes from the apex of the lung.
D. A similar procedure can be used to measure the anatomic dead space.
E. The test is very time consuming.
4. In the assessment of ventilation-perfusion inequalitybased on measure-
ment s of P02 and P
10 arterial blood and expired gas, all of the following
stat ements are true EXCEPT:
A. The ideal alveolar P02is calculated using the arterial Peo2'
B. The alveolar P 0 2 is then calculated from the alveolar gas equation.
C. VA/O inequality increases the alveolar-arterial P0 2 difference.
D. VA/a. inequality increases the physiologic shunt.
E. VA/a.inequality reduces the physiologic dead space.
5. A seated normal subject exhales to residual volume (RV).
A. The volume of gas remaining in the lung is more than half of the vital
B. The P
C0 2
of the expired gas falls just before the end of expirati on.
C. If the mouthpiece is closed at RVand the subject completely relaxes,
the pressure in the airways is greater than atmospheric pressure.
D. Intrapleural pressure exceeds alveolar pressure at RV.
E. All small airways in the lung are closed at RV.
Symbols, Units, and
Primary Symbols
Concentra tion of gas in blood
Fract ional conc entra tion in dry gas
Pressure or parti al pressure
Volume of blood
Volume of blood per unit time
Respiratory exchange rat io
Sat urat ion of hemoglobin with O
Volume of gas
Volume of gas per unit rime
,I: '
Secondary Symbols for Gas Phase
A Alveolar
B Barometric
D Dead space
E Expired
I Inspired
L Lung
T Tidal
Secondary Symbols for Blood Phase
a ar terial
c capillary
c' end-capillary
v venous
v mixed venous
concentration in arterial blood Cao,
Fractional concentrat ion of N
in expired gas FE\';2
Parti al pressure of O
in mixed venous blood Pvoz
(pressure constant]
= -
(temperature constant ) Boyle's law
and Charles' law
Also, in th e alveoli, Po, + P
, + P
, + P
= PB·
The partial pressureof a gas in solutionis its part ial pressure in a gas mixture that
is in equilibrium with the solut ion.
Henry's lawstates th at the concentration of gas dissolved in a liquid is propor-
tional to its part ial pressure. Thus, ex= K . Px-
are special cases of the general gas law.
Avogadro's lawstates that equal volumes of different gases at the same rernper-
ut ure and pressure contain th e same number of molecules. A gram molecule, for
example, 32 gill of 0 " occupies 22.4 liters at STPD.
Dalton's law stat es that the partial pressure of a gas [x] in a gas mi xtur e is the
pressure that this gas would exert if it occupied the total volume of th e mixt ure in
the absence of the other components.
Thus, P, = p . F
, where P is the total dry gas pressure, since F, refers to dry
gas. In gas with a water vapor pressure of 47 mm Hg
Gas Laws
General gas law: PV = RT
where 47 mm Hg is th e water vapor pressure at 3re.
273 P
- 47
-31-0 X
Tradit ional metric units have been used in this book. Pressures are given in mm
Hg. the W IT is an almost identical uni t.
In Europe. 51 (Svsteme Intern ati onal) units arc commonly used. Most of th ese
are familiar, but the kilopascal, the unit of pressure, is confusing at first. One kilo-
pascal = 7.5 mrn Hg (approx imatel y).
where T is temperature and R is a constant. This equat ion is used to correct gas
volumes for changes of water vapor pressure and temperature. For example, ven-
tilation is convent ionally reported at BTPS, that is, body temperature (3r C),
ambient pressure, and saturated with water vapor because it then corresponds to
the volume changes of the lung. By contrast, gas volumes in blood are expressed
as STPD, that is, standard temperature (O°C or 273°K) and pressure (760 mm Hg)
and dry, as is usual in chemistry. To convert a gas volume at BTPS to one at
STI'D, mult iply by
= V
+ VA
where VAhere refers to the volume of alveo lar gas in the tidal volume
VA = V
- V
Va>, = VA . FAco, (bot h Vmeasured at BTPS)
. V
e 0 2
VA = PAco
X K (alveo lar ventilation equation)
If VAis BTPS and Va>, is STPD, K = 0.863. In normal subjects, PA= , is nearly
ident ical to P"=z'
Bohr equntion
Or, using arterial p
PA= , - PEeo,
P"=, - PE=,
- =
This gives physiologic dead space.
In the gas phase, Graham's law states that the rat e of diffusion of a gas is inve rsely
proportional to the square root of its molecular weight .
In liquidor a tissueslice, Fick's law* states that the volume of gas per unit time
whic h diffuses across a tissue sheet is given by
. A
V,,, = T . 0 . (P, - P, )
where A and T are the area and thickness of the sheet , P, and P
are the part ial
pressure of the gas on the two sides, and D is a diffusion constant sometimes called
the permeability coe fficie nt of the tissue for that gas.
This diffusion constant is relat ed to the solubility (Sol) and the mol ecular
weight (MW) of the gas
On ~ M W
When the diffusing capacity of th e lung (Dc> is measured with carbon monoxide
and the capillary l'co is taken at zero,
0 - - -
L - PAeo
* Pick's law was originally expressed in terms of concent rations, but partial pressures are
more convenient for us.
is made up of two components. One is the diffusing capacity of the alveolar
membrane (D M), and the othe r depends on the volume of capillary blood (Vel
and the rate of reaction of CO with hemoglobin e
I I 1
- = - + --
Blood Flow
Fick principle
Pulmonary q,uscular resistance
Part - P \ T Il
where Parr and P
are the mean pulmona ry arterial and venous pressures, re-
spect ively.
StarhnK' 5 law of fluid exc hange across the capillaries
Net flow out = K[(P, - Pi) - <r(,., - ,.,)]
whe re i refers to the int erstit ial fluid around the capillary, 1T refers to the col-
loid osmotic pressure. (J' is the reflect ion coefficient. and K is the filtra t ion co-
effici en t.
Ventilation-Perfusion Relationships
Alveolargas equation
PAco, [ l -R]
PAo, = Pia , - --R- + PA"o,· Flo, · - R - -
This is only valid if there is no CO
in inspired gas. The term in square bracket s
is a relatively small correction factor when air is breat hed (2 mm lIg whe n P
= 40, Flo, = 0. 21, and R = 0.8). Thus, a useful approximat ion is -
Respiratoryexchange ratio
If no CO
is present in the inspired gas
PEco, (l - Flo, )
Pia , - PEo, - (PEc0
• Flo, )
Appendix A
Venous to arterial shun!
Qs CCo z - Caoz
Or Cc'o, - eva,
where c' means end-capillary.
ratio equation
VA 8.63 R(Cao, - CVo,)
Q = PAco,
where blood gas concentrations are in mI· 100 mt-
Physiologic shunt
Cia , - Cao,
Cio, - CVo,
Alwolar dead space
- PAC02
co 2
The equat ion for physiologic dead space is on p. 160.
Blood Gases and pH
a, dissolved in blood
Co, = Sol · Po,
where Sol is 0.003 ml Oj . 100 ml b1o<xl-
. mm Hg- I
lienderson,Hassdbalch equation
(HCO j)
pl-l =pKA + log (CO, )
I, ,,
The pKA for thi s system is normally 6.1. If HCO"l and CO
concentrations are in
millimoles per liter, CO, can be replaced by P
, (rnrn Hg) X 0.030.
Mechanics of Breathing
Complinnce = !:N /i1P
Specific compliance = i1V/( V . i1P)
Laplace equation for pressure caused oy surface tension of a sphere
P = -
where r is the radius. Note that for a soap bubble, P = 4T/r, because there arc
two surfaces .
where n is the coefficient of viscosity" and P is the pressure difference across the
lengt h l.
Re = --
where v is average linear velocity oft he gas, d is its density, and n is its viscosity.
Pressure drop for laminar flow, P«V, but for turbulent flow, Pc y2(approximately).
Airway resistance
P al\' - P mouth
where P ~ l l \ ' and P mouth refer to alveolar and mouth pressures, respectivel y.
Chapter 1 Chapter 5
1. E
1. D
2. 8
2. 8
3. 8
3. A
4. D
4. 8
5. 8 5 8
6. A 6. E
7. A
Chapter 2 8. E
1. 8
9. D
2. E
3. e
Chapter 6
4. D
1. D
5. 8
2. E
6. 8
3. E
4. E
Chapter 3
5. A
1. e
6. E
2. E
7. 8
3. E
8. e
4. A
9. A
5. A
10. A
6. D
11. E
12. E
Chapter 4
1. D
Chapter 7
2. e
1. e
3. E
2. E
4. E 3 A
5. e
4. E
6. E
5. D
7. D 6. D
8. A 7. e
9. A 8. D
10. E
9. 8
10. E
11. E
12. E
13. B
14. D
1. E
2. B
3. D
4. A
5. B
6. D
7. E
Chapter 9
1. E
2. C
3. E
4. D
5. E
6. B
7. D
Chapter 10
1. C
2. A
3. E
4. E
5. B

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