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[Downloaded free from http://www.ijaweb.org on Wednesday, February 08, 2017, IP: 186.86.2.

166]

Review Article

Anatomy and physiology of respiratory system
relevant to anaesthesia

Address for correspondence: Apeksh Patwa1,2, Amit Shah1,2
Dr. Apeksh Patwa, 1
Kailash Cancer Hospital and Research Centre, Muni Seva Ashram, Goraj, Vadodara 2Department of
B‑31/32, Kailash Park Duplex, Anaesthesia, Vadodara Institute of Neurological Sciences, Vadodara, Gujarat, India
Aims Oxygen Lane, Akshar
Chowk, Old Padra Road,
Vadodara ‑ 390 020, ABSTRACT
Gujarat, India.
E‑mail: apekshpatwa@
Clinical application of anatomical and physiological knowledge of respiratory system improves
gmail.com
patient’s safety during anaesthesia. It also optimises patient’s ventilatory condition and airway
patency. Such knowledge has influence on airway management, lung isolation during anaesthesia,
management of cases with respiratory disorders, respiratory endoluminal procedures and optimising
Access this article online ventilator strategies in the perioperative period. Understanding of ventilation, perfusion and their
Website: www.ijaweb.org relation with each other is important for understanding respiratory physiology. Ventilation to perfusion
ratio alters with anaesthesia, body position and with one‑lung anaesthesia. Hypoxic pulmonary
DOI: 10.4103/0019-5049.165849
vasoconstriction, an important safety mechanism, is inhibited by majority of the anaesthetic drugs.
Quick response code
Ventilation perfusion mismatch leads to reduced arterial oxygen concentration mainly because of
early closure of airway, thus leading to decreased ventilation and atelectasis during anaesthesia.
Various anaesthetic drugs alter neuronal control of the breathing and bronchomotor tone.

Key words: Anatomy, bronchomotor tone, functional residual capacity, physiology, respiratory
system, tracheobronchial tree, ventilation‑perfusion

INTRODUCTION in two zones; conducting zones (nose to bronchioles)
form a path for conduction of the inhaled gases and
Accurate knowledge of anatomy and physiology of the respiratory zone (alveolar duct to alveoli) where the
respiratory tract is important not only in the field of gas exchange takes place. Anatomically, respiratory
pulmonology but also in anaesthesiology and critical tract is divided into upper (organ outside thorax ‑ nose,
care. About 70–80% of the morbidity and mortality pharynx and larynx) and lower respiratory tract (organ
occurring in the perioperative period is associated within thorax ‑ trachea, bronchi, bronchioles, alveolar
with some form of respiratory dysfunction.[1] General duct and alveoli).
anaesthesia and paralysis are associated with alterations
in the respiratory function.[2,3] Dynamic anatomical The discussion is mainly concentrated on the lower
changes and physiological alteration happening during respiratory tract and the related physiology.
anaesthesia make it imperative for an anaesthesiologist
to have sound knowledge of the respiratory system and Nose and nasal cavity are divided into two halves
apply it for safe and smooth conduct of anaesthesia. by the nasal septum. The lateral wall of the nose
Such knowledge has influence on clinical practice of consists of three turbinates or conchae (superior,
airway management, lung isolation during anaesthesia,
management of cases with respiratory disorders, This is an open access article distributed under the terms of the Creative
respiratory endoluminal procedures and surgeries, Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
optimising ventilator strategies in perioperative period author is credited and the new creations are licensed under the identical terms.
and designing airway devices. For reprints contact: reprints@medknow.com

ANATOMY OF RESPIRATORY SYSTEM How to cite this article: Patwa A, Shah A. Anatomy and physiology
of respiratory system relevant to anaesthesia. Indian J Anaesth
The respiratory system, functionally, can be separated 2015;59:533-41.

© 2015 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow 533

inefficient contraction of pharyngeal dilator muscles.org on Wednesday.[8] Tracheal tug There are three narrowest portions of pharynx. The passage inferior to inferior Anatomical imbalance of oropharyngeal soft tissue turbinate is preferred passage for nasotracheal Enlarged tongue (in the case of acromegaly or intubation. ventilation and obstructive sleep apnoea. passage and larynx during inspiration because of negative posterior to the tongue (retroglossal space) and passage intrathoracic pressure which elongates pharyngeal posterior to epiglottis (retroepiglotic space).[5] difficult mask ventilation during anaesthesia. 59 | Issue 9 | Sep 2015 . stabilise the retroepiglotic laryngopharynx. Inefficient contraction of pharyngeal dilator muscles [Figure 2] TRACHEOBRONCHIAL TREE (1) The tensor palatine retracts the soft palate away from the posterior pharyngeal wall. each airway is being divided into fat deposition around these muscles would result in two smaller daughter airways[10] [Figure 3]. passage There is constant traction on trachea. pharynx posterior to the soft palate (retro palatal space). It is partitioned into 23 generations of dichotomous space.86.ijaweb.[4] The pharynx is a tube‑like passage that obesity) in normal bony enclosure of oropharynx connects the posterior nasal and oral cavities to the or a smaller bony enclosure (receding mandible) of larynx and oesophagus. Hypo pharyngeal in bony enclosure size would result in anatomical tongue decreases laryngopharyngeal airway patency. (2) The genioglossus trachea down to the acini. and anaesthesia[6] which would lead to upper airway This is also one of the reasons for difficult mask obstruction. thereby It is a complex system that transports gases from the maintaining retro palatal patency. sternohyoid branching. imbalance and cause limitation of space available for This is one reason for obstructive sleep apnoea and airway [Figure 1]. 2017. It is divided into nasopharynx. This would lead to pharyngeal airway obstruction From the trachea to the terminal bronchioles (generation 15–16). oropharynx would be unable to accommodate the oropharynx and laryngopharynx. IP: 186. Increase in soft tongue into oropharynx and thus shift the tongue into tissue within bony enclosure of pharynx or decrease hypopharynx (laryngopharynx). February 08. extending from trachea (generation 0) to and thyrohyoid) make the hyoid move anteriorly and the last order of terminal bronchioles (generation 23). the airways are purely conducting pipes. transmitting air from oropharynx and nasopharynx to trachea.[Downloaded free from http://www. Since during sedation and anaesthesia. the gas exchange units of the moves the tongue anteriorly to open the retroglossal lung. (3) Hyoid muscles (geniohyoid. Excessive At each generation.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia middle and inferior). There is airway during inspiration that would result in significant reduction of these spaces with sedation decreased pharyngeal luminal space in obese patients.2.[7] Figure 1: Excessive soft tissue (obesity) in fix bony enclosure leads Figure 2: Upper airway showing pharyngeal dilator muscles and to compromised pharyngeal passage pharyngeal airway space 534 Indian Journal of Anaesthesia | Vol.[9] ANATOMICAL FACTORS WHICH COMPROMISES Larynx PHARYNGEAL PATENCY It serves as a sphincter.

ijaweb.[15] The trachea is generally midline in position. body position and position of tissues (gas exchange units) of lung.[13.org on Wednesday. the volume in bifurcation is called as the carinal/subcarinal angle. bronchioles (generations 17–19) as they have occasional alveoli at the walls. these pipes is called as the dead space volume (average which is measured commonly as 73° (35–90°). Each antero‑posteior tracheal lumen in forced expiration. convex or slightly BRONCHO‑PULMONARY SEGMENT concave. there are ten often displaced slightly to the right and posteriorly broncho‑pulmonary segments in each lung. February 08. The left bronchus passes inferolaterally at 11–13 cm.2. The posterior tracheal wall lacks into (secondary bronchi) the left upper and lower lobe cartilage and is supported by the trachealis muscle. stem bronchus has a more direct downward course.[16‑18] The 150 ml). Depending on the level of inspiration. the posterior wall of the trachea becomes flat. with 2–4 cm being extra‑thoracic. Broncho‑pulmonary segment may be defined as an In normal subjects.[11] This leads to higher chances of right endobronchial intubation. 2017. lobar bronchi divides into segmental bronchi (tertiary whereas the transverse diameter decreases only by bronchi). It extends from the level of C6 (cricoid right upper lobe bronchus and bronchus intermedius cartilage) to the carina. approximately located at the which further divides into right middle and lower lobe level of T4–T5. in females and obese patients.[19] This explains the change in position are small tubes supported by a rich matrix of elastic of endotracheal tube during change in position of and collagen fibres. The terminal bronchioles (generation 16) carinal angle is wider in individuals with an enlarged divide into respiratory bronchioles or transitional left atrium. The alveolar ducts diaphragm.86. Technically. The distal ends of alveolar ducts patient or flexion – extension of neck. bronchi. its length is approximately bronchus.[12] The a greater angle from the vertical axis than the right trachea has 16 to 22 horseshoe bands (c‑shaped) bronchus. These respiratory bronchioles The trachea divides at carina into the right and left further divide into alveolar ducts (generations 20–22) main bronchus.[11] In adults. This region the teeth varies markedly with change in neck is known as acinus (generations 16–23). which supply the broncho‑pulmonary 13%. The Figure 3: Tracheobronchial tree showing 23 generations Figure 4: Tracheobronchial tree with broncho-pulmonary segments Indian Journal of Anaesthesia | Vol. there is up to 35% reduction in area of distribution of any bronchus [Figure 4]. The right The trachea is a hollow conduit for gases and bronchial main stem bronchus divides into (secondary bronchi) secretions. but in as it approaches carina. The right main open into the alveolar sac which is made up by alveoli.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia no gas exchanges take place in this region.14] The posterior wall of the trachea either flattens or bows slightly forward during expiration. The angle of the tracheal left lung. The acinus is position from flexion to extension (tracheal length comprised of respiratory airways and forms functional variation is ± 2 cm). is shorter than the left and begins to ramify earlier TRACHEA AND RIGHT/LEFT MAIN BRONCHUS than the left main bronchus. The left main stem bronchus divides of cartilages. some of these segments fuse and there are as few as eight broncho‑pulmonary segments. 59 | Issue 9 | Sep 2015 535 . segment of each lobe.[Downloaded free from http://www. IP: 186. The distance of the carina from which are completely lined with alveoli.

[27] 536 Indian Journal of Anaesthesia | Vol.5-5 cm 11.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia bronchi continue to divide into smaller and smaller 0.[22] There is a strong positive correlation between average tracheal length and body height. of intubation. Gases remaining in the lungs at the end side of the trachea above the carina and within 2–6 cm of expiration not only prevent alveolar collapse but from it.5 cm2 [12. lung compliance. When an individual.08%. volumes.[Downloaded free from http://www. When bronchi lose all cartilaginous Accessory cardiac bronchus support.3–1%. their structure the cases of obstruction to its entrance or tube entering changes: into it during intubation.18. Its prevalence is 0.ijaweb. 59 | Issue 9 | Sep 2015 .21] 10-21 mm in women 10-23 mm in women Diameter Right main bronchus 1.86.[20] and expiratory reserve volume whenever required (e.org on Wednesday. diameters and angulations Normal requirements of the body can be easily met helps optimizing procedures such as intubation.5-3 cm 15 mm 2. exercise).[30‑34] The tracheal bronchus may cause bronchi up to 23 generations of divisions from main complications such as atelectasis or pneumothorax in bronchus. lung isolation techniques and other endo‑bronchial procedures. IP: 186. such as age.[28] The most breath and is 4–5 L in an average 70 kg individual.24] The right bronchus length and diameter can be altered by many causes.20. by normal tidal ventilation which is approximately lung isolation techniques and jet ventilation during 4–8 ml/kg.[35‑37] • Cartilaginous ring becomes irregular and then disappear.g. the airway is then referred as It is a congenital.[22] Tracheal length decreases with age over 70. alveoli which prevents it from collapsing.[22. FRC is Tracheal bronchus basically the amount of air in the lungs after a normal This is a bronchus usually originating from the right expiration. takes full inspiratory breath followed by Tracheobronchial tree exhibits a wide range of expiration to reserve volume. ventilation-perfusion and bronchomotor tone are essential for clinical DIMENSIONS OF TRACHEOBRONCHIAL TREE application of respiratory physiology in anaesthesia [TABLE 1] and critical care.[31] It columnar to columnar to cuboidal in the is associated with recurrent infections in few cases. intraluminal pressure. Residual volume with expiratory reserve volume is called as functional residual capacity (FRC).[26] and respiratory phase. The volume Knowledge of tracheobronchial variants is important remaining in the lungs after vital capacity breath is for clinical aspect in pre‑operative evaluation in view called as residual volume.20] Subcarinal angle 35-90° (average 73°) [16‑18] Males have larger diameters and length of tracheobronchial tree while female has larger main stem bronchial angles. short and thin bronchus towards bronchioles pericardium originating either from right bronchus or • The epithelium changes from pseudostratified intermediate bronchus.1–2% and left bronchus has a prevalence of flowing though the capillaries during this time Table 1: Dimensions and features of tracheobronchial tree Length Coronal diameter Sagittal diameter Cross sectional area References Trachea 11‑13 cm 13-25 mm in men 13-27 mm in men 3. 2017.[25] The tracheobronchial size and shape varies with body position.[38] terminal bronchioles PHYSIOLOGY OF RESPIRATORY SYSTEM • There are no cilia and mucous producing cells in bronchioles Movement of inspired gas into and exhaled gas out of • The amount of smooth muscle in the tube wall lung is called as ventilation.[23] The right main stem bronchus is 1 mm wider than the left main bronchus. Understanding of lung increases as the airway becomes smaller.[29] Right tracheal bronchus has a prevalence also it continues to oxygenate the pulmonary blood of 0.1 [17. previous pulmonary diseases and patient height.8-13 mm 2.[22] Trachea is much more vertical in youth than in old age. As bronchi become smaller. Body has kept mechanism to provide extra interventional endoscopic surgeries of trachea or ventilation in the form of inspiratory reserve volume bronchi.2 [20] Left main bronchus 4. February 08.. after tidal Tracheobronchial anatomical variations expiration. common main bronchus anomalies are the tracheal There is always some amount of air remaining in the bronchus and the accessory cardiac bronchus. it is called as vital capacity variations and its prevalence is 4%.2.2-3. Ascertaining the parameters of tracheobronchial Lung volumes [Figure 5] tree such as length.

Since lung blood flow passes preferentially to Compliance (ability of lung to distend) depends upon dependent regions.[39] preferential distribution of ventilation to the alveoli at the base of the lungs in upright posture.1 L[40] in lung. In upright position. Reduction in FRC promotes airway Compliance and ventilation of lung closure in dependent lung regions. Intra‑Ppl becomes 0. This explains the perfusion ratio approximately one. Early airway Compliance is expressed as the distension of lung for closure thus decreases ventilation in the dependent a given level of Ptp. In the upright reports but on average it is between 2. lateral or prone reduces FRC. lungs.8 and 3. Distribution RESPIRATORY MECHANICS of ventilation changes with the position of individual because of the change of Ppl with the gravity.3 L/cm H2O. 2017. This makes alveolar ventilation to compliant than other area of lung.[39] Reported FRC values vary with various distend to a given pressure [Figure 6]. apical region becomes less output 5 L/min). matching between ventilation and the volume of the lung.5 cm of H2O.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia period. Ppl = Pleural pressure). This means that the alveoli at alveoli and takes part in the gas exchange is called the apex are exposed to a greater distending pressure as alveolar ventilation. height of lung is about 35 cm.[42] The volume remaining the lungs during inspiratory phase.[43] extremes of FRC.2 cm H2O positive for every anaesthesia and body weight.5  cm H2O). February 08. In normal respiration. expressed by the following equation: closing capacity approaches near FRC in older individual (65–70 years) which would result in airway Ptp = Paw−Ppl. It implies that expanded lung and completely deflated lung has lower capacity to Perfusion of lung Pulmonary circulation differs from systemic circulation. Distending pressure can and this volume added to the residual volume is be known as transpulmonary pressure (Ptp). Average prolongs non‑hypoxic apnoea time. body position from upright to supine. which is termed as the closing capacity. 59 | Issue 9 | Sep 2015 537 .5) =1.ijaweb.[Downloaded free from http://www. Understanding of above the residual volume where expiration below distending pressure is very important to understand FRC closes some airways is termed as closing volume the respiratory mechanics. the volume of blood flowing through the lung (cardiac As already distended. FRC is the reserve which centimetre distance from apex to base of lung.  (Ptp  =  transpulmonary pressure. Lungs are like inflatable balloon which distend actively by positive pressure inside and/or negative pressure Airway closure during expiration is normal created in pleural space. Change in Paw = alveolar pressure. Normal value of alveolar (PA−Ppl = 0 − (−8) =8 cm H2O) compared to those ventilation is approximately 5 L/min which is similar to at the base (PA−Ppl  =  0 −  (−1. FRC varies with change of position. IP: 186. The pulmonary vessels are thin‑walled and have less Figure 5: Lung volumes Figure 6: Transpulmonary pressure Indian Journal of Anaesthesia | Vol. with reopening of airways during the negative pleural pressure (Ppl) is sufficient to distend succeeding inspiration. closure even at normal tidal expiration. intra‑Ppl varies from the top to the base of the standing position.2. Compliance is lowest at perfusion is impeded. phenomenon. It is usually 0.org on Wednesday.86.2–0. In quite breathing.[41] regions. the intra‑Ppl at apex is about − 8 cm of H2O while at base The portion of the minute ventilation which reaches it is − 1.

nondependent lung gets more ventilation while dependent lung gets On the basis of the influence of gravity. but perfusion increases more in comparison to ventilation. no occurs in response to low alveolar oxygen tension. Since PA > Pa > Pv in zone I. Pulmonary artery pressure is high during exercise. ANAESTHESIA In middle zone or zone II. eliminating any existing zone I into zone II and moving the boundary between zones III and II upward Ventilation to perfusion matching The alveolar partial pressure of oxygen and carbon dioxide are determined by the ratio of ventilation (V) to perfusion (Q). difference of Pa to PA decides Supine position the perfusion (Pa > PA > Pv) while in lower zone or General anaesthesia promotes basal atelectasis zone III. Paw changes are minimal airway closure in tidal breathing with supine position. As discussed earlier. This gradient occurs in are subjected to less pressure compared to systemic vertical axis of the lung fields irrespective of body circulation. 15–20% of the lung is atelectatic during due to the weight of lungs. IP: 186. exercise and other conditions. 2017. 59 | Issue 9 | Sep 2015 .ijaweb. during the course of a quiet breath but they are much promotes ventilation perfusion mismatch (V/Q < 1) greater during speech. Though such zone I do inhalation agents except newer agents. ventilation and perfusion both increase from top to bottom in lungs.[44] If patient is in lateral posture. Because of less pressure and structural positions. They base of lungs [Figure 7]. pulmonary arterial pressure (Pa) and pulmonary venous pressure (Pv). Atelectasis decreases towards The zones described earlier are purely physiological the apex. All as physiological dead space. and impairment of gas exchange.[Downloaded free from http://www. (i. which usually remains aerated.2. The borders between zones changes area of atelectasis becomes the area of shunt where with many physiological and pathophysiological no gas exchange occurs in spite of perfusion. Early alterations or conditions. Nearly.[47] haemorrhage or during general anaesthesia resulting in zone I conditions.[39] pressure. has more ventilation while base has more perfusion. inhibit the HPV. HPV considered as zone I.[42] The and not anatomical. Hypoxic pulmonary vasoconstriction (HPV) is compensatory blood flow away from hypoxic Apical region where PA can be higher than Pa and Pv is lung regions to better oxygenated regions. ratio of ventilation to perfusion is more in upper lung and less towards the Figure 7: Ventilation perfusion ratio from apex to the base of lung 538 Indian Journal of Anaesthesia | Vol. Pa alters with severe subject.86. apex differences of pulmonary vasculature to assist diffusion.[45] The distribution of blood flow in these zones depends upon three HYPOXIC PULMONARY VASOCONSTRICTION factors: Alveolar pressure (PA). in condition of haemorrhage or positive pressure. February 08. perfusion of more perfusion).. The combination of The patients on positive pressure ventilation with atelectasis and airway closure explains about 75% of positive end expiratory pressure (PEEP) may have the overall impairment in oxygenation in anaesthetised substantial zone I due to high PAs. Proportionately. difference of Pa to Pv (Pa > Pv > PA) decides irrespective of the modes of ventilation (spontaneous the perfusion.org on Wednesday. lung is divided into three zones. they are subjected to Paw inside the thorax and gravity. ventilation zone I may become reality and PHYSIOLOGICAL VARIATION WITH POSITION AND adds to dead space ventilation.[46] general anaesthesia. sevoflurane not exist in healthy subject under normal perfusion and desflurane.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia musculature to assist fast diffusion of gases. if patient is in upright posture. arterial blood flow occurs and this zone is considered This mechanism improves the V/Q mismatch.e. Few studies also include 4th zone of less or controlled) or drugs (intravenous or inhalation) blood supply because of the compression of vessels used.

Number 2. is inhibited by majority of anaesthetic post‑inspiratory phase. Such uniform gas distribution and less lung compression knowledge has influence on the clinical practice of by heart) have been proposed by different authors for airway management. BRONCHOMOTOR TONE REFERENCES Bronchomotor tone is the state of contraction or 1.[49] Sevoflurane (1 minimum PEEP. walls that regulates the calibre of the airways. tomography. Financial support and sponsorship hypercapnia and hydrogen ion concentration.2. uniform vertical distribution of of respiratory system definitely improves safety of perfusion. One should avoid drugs causing inhibition of In contrast.[Downloaded free from http://www.[47] During one‑lung ventilation. Overall ventilation to perfusion ratio inspiratory phase of sudden discharge of signals to is 1 but it alters with anaesthesia. an important safety pharynx.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia Lateral position and one‑lung ventilation of factors influences the change of bronchomotor Anaesthesia in lateral position causes ventilation tone. February 08. increased FRC. Strandberg A. resistance.g. lung. Various anaesthetic drugs alter neuronal chemoreceptors. Physiology of respiratory system related to relaxation of the smooth muscle in the bronchial anesthesia. applying jet ventilation during emergency and endoluminal surgeries and designing airway devices. HPV.. With addition of at low concentrations. HPV resistance (determined using an isovolume technique) can divert blood flow away from the non‑ventilated by 15% in patients undergoing elective surgery.org on Wednesday. Hedenstierna G. Indian Journal of Anaesthesia | Vol. rhythm and intensity of discharge from ventilation and atelectasis occurring with the the respiratory centres which receive inputs from the anaesthesia. Brismar B. followed by gradual decline of signals in mechanism. probably respiratory endoluminal procedures and surgeries.86. improvement in ventilation with prone position. more ventilatory condition and airway patency. had showed that halothane Dependent lung also exhibits signs of early airway causes greater broncho‑dilatation than isoflurane closure and formation of atelectasis.[50] Prone position SUMMARY Prone position decreases ventilation perfusion mismatch and improves the oxygenation. are no reports of atelectasis in prone position. drugs and various perfusion mismatch where upper or nondependent procedures on airway. They contain different types of capacity is an important determinant of ventilation of inspiratory and expiratory neurons that fire during patient. depth of anaesthesia. lung isolation during anaesthesia. Ventilation and perfusion both are affected the three phases of the respiratory cycle.[42] period. almost 80% of blood flow is directed to lower alveolar concentration) reduced respiratory system dependent lung. pharyngeal control of the breathing and bronchomotor tone. body positions and inspiratory muscles and the dilator muscles of the with one‑lung anaesthesia. respiratory diseases (bronchial lung receives more ventilation and lower or asthma) and inhalational agents. Peripheral chemoreceptors respond quickly to hypoxia.7:163‑80. namely by the gravity. Using computed dependent lung receives higher (60–65%) perfusion.[48] Inhalational agents because of early closure of airway leading to decreased influence rate. vagus nerve and other afferents. hypothalamus. central chemoreceptors are slow responders relative to peripheral chemoreceptors.g. There management of cases with respiratory disorders. better ventilation distribution because of conduct of anaesthesia and also optimises patient smaller vertical pleural gradient. desflurane did not significantly alter HPV. NEUROLOGICAL CONTROL OF BREATHING An anaesthesiologist should understand that FRC is The respiratory centres are located in pons the most important parameter. 2017. Its relation with closing and medulla. IP: 186. Drain CB. cortex. CRNA 1996. mechanoreceptors. The Nil.ijaweb. Ventilation perfusion mismatch leading to signals in expiratory phase except in forced expiration reduced arterial oxygen concentration is mainly or high minute ventilation. Conflicts of interest There are no conflicts of interest. Various Clinical application of the anatomical knowledge reasons (e. Inspiration is followed by no drugs. Lundquist H. because weight of heart transferred on the sternum optimising ventilator strategies in perioperative instead of lungs as opposed to supine position. Brown et al. e. 59 | Issue 9 | Sep 2015 539 .

Dondelinger RF. Fanchamps JM. 14. 10.14:271‑4. Miller’s Anesthesia. AJR Am J Roentgenol 2007. p. Respir Physiol 1968. Thorac Surg Clin 2007. 42. London: BC Decker Inc. Kayacan O. Griscom NT.I. Tanrikulu AC. 37. Tanaka A.10:e0123177. Hsu CH. et al. 3D CT demonstration in nine cases. Downie GH. anatomy for thoracic inlet.76:573‑5. Isono S. Advanced visualization patient: Implications for airway management. Pathways through the Artifon EL. AJR Am J Roentgenol 2000. Hughes JM.1:105‑19. Mi W. 25. Eur Radiol 1999. Measurement J Appl Physiol 1964. Congenital bronchial abnormalities revisited. p. glottis and subglottis. J Appl Physiol 2008. Br J Radiol 2005. Is there a correlation between right bronchus nose for nasal intubation: A comparison of three endotracheal length and diameter with age? J Thorac Dis 2013. Tracheal size and shape: Effects of 5. Static properties of the multidetector CT. 33. Horton KM. Aydin A. Tokics L. Crocker D. Metha A. Prediction equations for plethysmographic 15. Surgery of the Trachea and Bronchi.17:299‑301. Lung India 2011. 3‑15.17:639‑59. Large hypopharyngeal tongue: A shared 31. Küpeli E. 39. Ghaye B. Congenital bronchial Anaesth Intensive Care 1994. Carneiro FO. Wittenborg MH. volume on the distribution of pulmonary blood flow in man. Ugalde P. 2005.68:454‑9. Yang L. Ahmed-Nusrath A.94:27‑31.189:1387‑96. 8. Santesson J. Hirabayashi Y. and segments. Br J Anaesth 2000. Multiplanar and lung volumes. study to investigate the basis for double‑lumen tube selection.[Downloaded free from http://www. Tracheobronchial Respirology 2012. February 08. in isolated lung. Radiographics 2001. Tanzawa H. sedated and tracheobronchial variations.94:936‑7.104:1539. 3. Wu TL. hilum and pulmonary vascular system.5:306‑9. The relationship between the diameters of the with muscular relaxation – A proposal of atelectasis.22:165‑9. change in intraluminal pressure. Fréchette E. 2nd ed. Kos X. The Lung: Scientific Foundations. expiratory high‑resolution computed tomography. AJR Am J Roentgenol 1984. Dollery CT. 23. Horton MR. Morris I. Roussos C. Airway closure.62:422‑8. Reynolds KF. Clin Anat 2008. Heidelberg: Springer.C. AJR Am J Roentgenol 1982. 28. Chou HC. IP: 186. Rodriguez‑Roisin R. 110‑35. 22. Accessory cardiac bronchus: lymphatics.149:27‑30. The anatomy of the bronchial tree. trachea. Pain. lobes. bronchi. 59 | Issue 9 | Sep 2015 . Beder S. Hedenstierna G. flow in the human lung. Ghaye B. Distribution of blood flow Otolaryngol 1958. Ho ST. 2015. Elicker BM. atelectasis and gas exchange during general 540 Indian Journal of Anaesthesia | Vol.20:789‑811. Hedenstierna G. Saad C. Gas exchange during anaesthesia. Eur Radiol 40. Van Beek EJ. Implications of a tracheal bronchus for adult 12. Effect of lung using computed tomography. In: Morphometry of the Human Lung. 29. Wang H. Abakay O. Akazawa S. Velez E. PLoS One 2015. West JB.19:713‑24.org on Wednesday. bronchus: A rare tracheobronchial anomaly. Respir Med 1998. et al. Anaesthesiol Scand Suppl 1990. Last word on point: Counterpoint: Gravity 20.. et al. Baehrendtz S.78:787‑90. Radiology 1967. 2003.100:269-74. editor. Söderborg B. Dahlborn M. Breatnach E. Grassino AE. 44. Correlative tracheal bronchus. Cherng CH. 2004.28:180‑3. and analysis of the tracheobronchial tree in Chinese population 46. Kavanach B. Burgos F. Fraser RG. Klingstedt C. Mitsuhata H. Pulmonary densities during anesthesia 24. 444‑72. Ghaye B. Care Med 2002. Obstructive sleep apnea in the adult obese 30. 1187‑202. Graziotti P. Thorac Surg Clin 2007. Grillo HC. J Clin Anesth 2002. Milan: implications. Tracheal bronchus. Contribution of body habitus and craniofacial characteristics 27. orotracheal intubation. p. Hast J. Radiology 1983. Heussel CP. Aoun NY. stridor. West JB. Abakay A. Webb WR. In: Miller RD. Radiographics 9. Sunyer J. Ley S. CT assessment of tracheal carinal angle and its New York: New Raven. nonneoplastic tracheal abnormalities: Appearance of the 36. Isono S. 26. Webb EM. Tracheal dynamics to segmental closing pressures of the passive pharynx in in infants with respiratory distress. Ernst A. Ikeno S. bronchial arteries and 38. Wegenius G. 43‑51. Glazier JB. AJR Am J Roentgenol 2002.179:301‑8. Minnich DJ. Philadelphia: Elsevier. Karabulut N. Minamoto H. 2017. Hedenstierna G. Rothen HU.E. Zhang C. angle in different age groups in both sexes and its clinical Intensive Care and Emergency Medicine–A. tracheal wall. Gyepes MT. et al. Geometry and dimensions of airways of conductive 34. Otoch JP. Watanabe T. Conacher ID. Shorten GD. determinants. Using CT to diagnose anaesthetic practice. relation to vascular and alveolar pressures. Hedenstierna G. 7. 47.174:1315‑21. Anatomy of the trachea.4:424‑30. Accessory cardiac bronchus. Opie NJ. Diseases. Results of Treatment. Brock RC. 1997. Wohl ME. p. 18. Macklem PT. and collapsing patients with sleep‑disordered breathing. adults: Estimation of the optimal endotracheal tube length for Anesthesiology 1984. reassessment. Acta J Cardiothorac Vasc Anesth 2003. Karnak D. 35. Khurshid I. lung area and mean lung density at paired inspiratory/ 8th ed. Chunder R. Effects of body position on ventilation/ 17.9:311‑2.21:531‑8. Airway management for patients with a 13.17:32‑42. Normal tracheal bifurcation angle: A 43. Ederle JR.139:879‑82. Khangure M. Goodman LR. Hedenstierna G.2. p. Miro S. Carkanat AI. Li C.P. adult cricoid ring and main tracheobronchial tree: A cadaver Anesthesiology 1985. three‑dimensional imaging of the central airways with 41. 6. Dimensions of the normal is/is not the major factor determining the distribution of blood human trachea. variations in Turkish population. Benumof JL. Fanchamps JM. Barberà JA. Clinical and demographic characteristics of Assessment of upper airway anatomy in awake. Anaesthesia. Sen HS. Tong JL. de Almeida 4. Boiselle PM. J Bronchology 11. abnormalities revisited. for increased collapsibility of the passive pharyngeal airway.85:317‑20. Anderson LC.4:58‑72.92:454‑60. 21. Weibel ER.21:105‑19. editor. Nishino T. Airway length in each lung during differential ventilation with selective PEEP. Haskin PH. Szapiro D. Wong CS. 2001. Smith JE. and obstructive sleep apnea? Anesthesiology 32. Ventilation and perfusion of 19. Anesthesiol of airways with 64‑MDCT: 3D mapping and virtual Clin North America 2002. Szapiro D. Roca J.49:1056‑8.ijaweb. 16. Br J Anaesth 1996. Tracheal accessory and transitory zones.61:369‑76. difficult 2002.88:653‑62. In: Gulio A. and main bronchi. Cao J. Respir Care 2004. Trayner EE. Engberg G. Evaluation of changes in central airway dimensions. West JB. Kenney LA. Sporre B. lung and chest wall. Perini M. Deslauriers J.86. Fischer B. A morphometric study of human subcarinal perfusion matching. Br J Anaesth 2008. 1963. fissures. Abbott GC. Fishman EK. Maloney JE. Diagnosis. and 2003. AMA Arch 45. Dondelinger RF. pathophysiology. carina. Obesity and obstructive sleep apnoea: Mechanisms 2001. carina.142:903‑6. Guha R. Seymour AH. Indian J Basic Appl Med Res 2015.165:260‑5.9:45‑8.10:58‑60. tubes. bronchoscopy. lobe take‑off and quadrifurcation of right upper lobe Berlin. Saito K.166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia Svensson L.13:2454‑61. Springer. anaesthetised patients using magnetic resonance imaging. et al. J Bronchology anatomic abnormality for difficult mask ventilation. Am J Respir Crit trachea.17:571‑85. Respiratory physiology and et al. Naimark A. Castellsagué J. Mathisen DJ. Kasuda H. Hughes M. intubation.

166] Patwa and Shah: Anatomy and physiology of respiratory system relevant to anaesthesia anaesthesia. TANDA (HP) Contact: +91 98640 23709 Organising Chairman: Dr. Dehradun Venue: B.com.html centralzonempisacon2015@gmail.93:404‑8.2.com E-mail: iapa8@cmcvellore. 31st Annual Conference of Indian Name of the conference: 25th Joint Annual Conference of ISA East Zone & 36th Society of Anaesthesiologists. H G Bhavsar Organising Secretary: Dr. Uhrich TD.com Name of the conference: AORA 2015 5th National Conference of Academy of Website: www. Br J Anaesth 1998. Kolkatta Contact: +91 98450 25236 Organising Secretary: Dr. Near IISC. Karnataka State Chapter Annual State Conference of ISA West Bengal State Branch . Ficke DJ.ac. Mills GH. Br J Anesth 50.com (visit isaweb. Respiratory physiology and anaesthesia.isawb.com Name of the conference: 28th Assam State Branch ISA Conference ABISACON 2015 Date: 3rd to 4th October 2015 Name of the conference: 16th North Zone ISACON 2015 Venue: NEDFi Building.com E-mail: subhendusarkar757@gmail. Sanjeev Nivargi Organising Secretary: Dr. Sajan Philip George Organising Secretary: Dr.ISAJAC 2015 Date: 9th to 11th October 2015 Date: 6th to 8th November 2015 Venue: S N Medical College.ijaweb.isampchapter. 2017. Jogendra Narayan Goswami Venue: Dr.com Name of the conference: AOACON Name of the conference: 7th Annual Conference of ICA Date: 11th to 13th September 2015 Date: 13th to 15th November 2015 Venue: Hotel Marriot. Anesthesiology 1993. Brown RH. Ramesh Koppal Organising Chairperson: Dr. Bagalkot Venue: Hotel The Stadel. Zulfiqar Ali Organising Secretary: Dr.com.com. Sunil T Pandya Organising Secretary: Dr.prernaanaesthesia. February 08.[Downloaded free from http://www. Kangra. Conference: Gulmarg (J&K) Venue: Motel Shiraz. Arain SR. Subhendu Sarkar E-mail: aoraindia2015@gmail.com E-mail: mpisaconcentzone2015@gmail. Anesthesiology concentrations of halothane and isoflurane as bronchodilators.in Website: www. Medical College.in ISA > ICACON2015) Website: http://www. Bhopal Organising Secretary: Dr. +91 98487 42426 Contact: +91 98410 29259 E-mail: aoahyderabad2015@gmail. Hirshman CA. Kolkata Organising Secretary: Dr.78:1097‑101. Sudarshan Kumar E-mail: jogengo74@gmail. 2000. sarkar_subhendu@yahoo. M. Sumanta Dasgupta.ncpa2016.com Name of the conference: 7th Central Zone Conference & 29th MP State Name of the conference: 6th National Airway Conference 2015 (NAC 2015) Conference 2015 Date: 18th to 20th September 2015 Date: 3rd to 4th October 2015 Venue: Workshop: Srinagar.gisacon2015. Bengalur Organising Secretary: Dr. Subhrndu Sarkar E-mail: rameshkoppaldr@gmail.com E-mail: suresh3559@yahoo.com Website: www.com Contact: +91 98311 71162 Website: www. Suresh Bhargava Contact: +91 78959 00714 Contact: +91 98290 63830 E-mail: sanjeev.in Indian Journal of Anaesthesia | Vol.com.isacon2015jaipur.com Contact: +91 98311 71162 Website: http://www. Ekta Rai Contact: +91 98242 33694 Contact: 0416-228-2105 / 3556 E-mail: info@gisacon2015.com Website: www. R G Agrawal Organising Chairperson: Dr. Announcement Conference Calender . Chennai 600004 Organising Secretary: Dr. Hyderabad Venue: Hotel Savera.86. Goff MJ.com E-mail: ica2015@gmail. Comparison of low A comparison to sevoflurane and thiopental. Vellore Organising Chairman: Dr. Rajendra Prasad Govt. Radhakrishnan Road. Christian Medical College. Mobile: 9002080513 Contact: +91 98455 04515 Organising Secretary: Dr. 59 | Issue 9 | Sep 2015 541 . Dr. IP: 186. Website: http://aidiaa.com E-mail: subhendusarkar757@gmail.81:681‑6.nivargi@maxhealthcare. +91 89591 13801 E-mail: nacsrinagar2015@gmail.in Name of the conference: 48th Gujarat State Conference of Indian Society of Anaesthesiologists 2015 (GISACON 2015) Name of the conference: 8th National Conference of Paediatric Anaesthesia 2016 Date: 9th to 11th October 2015 Date: 28th to 30th January 2016 Venue: Shanku’s Water World Resort (Ahmedabad-Mehsana Highway) Venue: Scudder Auditorium. Birla Auditorium & Convention Centre. Absence of bronchodilation during desflurane anesthesia: 49.com Name of the conference: KISACON2015. Guwahati Date: 16th to 18th October 2015 Organising Secretary: Dr. Jaipur. CEPD Rev 2001. 48. India Organising Secretary: Dr. K.1:35‑9.aora2015.kisacon2015.org on Wednesday. drskraikwar@gmail. MP Nagar. Balakrishnan Contact: +91 98483 10000. suniltp05@gmail. Ebert TJ.com Regional Anaesthesia of India Name of the conference: ISA JAC 25th East Zone Conference Date: 25th to 27th September 2015 Date: 6th to 8th November 2015 Venue: J N Tata Auditorium.2015 Name of the conference: 63rd Annual National Conference of the Indian Name of the conference: ukisacon 2015 Uttrakhand State ISA Conference 2015 Society of Anaesthesiologists.org/NAC2015/NAC_home. ISACON 2015 Date: 27th to 29th November 2015 Date: 25th to 29th December 2015 Venue: Max Hospital. Zerhouni EA. Kumar M V Venue: Hotel The Stadel.com Website: www. Surendra Raikwar Contact: +91 94190 86761 Contact: +91 94065 33300.