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3. What happens to FRC, ERV, IRV, and VC when a person lies
F.01 Respiratory Physiology supine from a standing position? Why?

Expiratory Reserve Decrease

OUTLINE Volume
I. Spirometry: Lung capacities and volumes
Functional Residual Decrease
II. Respiratory Calculations: Lung volumes, dead
Capacity
space and alveolar ventilation
III. Measurement of Peak Expiratory Flow Rate
IV. Examination of Chest and Lungs Inspiratory Reserve Increase
V. Case 1 Volume
VI. Case 2
VII. Case 3 Vital Capacity Decrease

Total Lung Capacity Decrease

I. SPIROMETRY: LUNG CAPACITIES AND VOLUMES
Spirometry is a basic pulmonary function test which measures the
amount of air inspired and expired.
● Detecting lung diseases
● Determining the degree of impairment
● Monitoring the effects of environmental and occupational
exposure
● Determining the effects of medication
1. Diagram the pulmonary volumes and capacities and label
the following: RV, IRV, TLC, TV, ERV, FRC, VC and IC.
Functional residual capacity decreases as a result of a decrease in the
expiratory reserve volume, compared to an erect position. However,
the decrease in the functional residual capacity results in an increase in
the inspiratory reserve volume. Since the venous return to the thorax
increases in supine position, the vital capacity and the total lung
capacity may decrease.
II. RESPIRATORY CALCULATIONS: LUNG VOLUMES,
DEAD SPACE AND ALVEOLAR VENTILATION
1. Using the information provided in figure 1-1, what are the
values for the tidal volume, inspiratory capacity, expiratory
reserve volume, functional residual capacity, vital capacity,
and total lung capacity?

2. Draw the flow volume loop of the following: Tidal Volume 500ml

Inspiratory Capacity 3500ml

Expiratory Reserve Volume 1000ml

Functional Residual 2500ml

Capacity

Vital Capacity 4500ml

Total Lung Capacity 6000ml

2. What is the name of the volume remaining in the lungs

after maximal expiration that is not measurable by
spirometry? What other lung volumes or capacities are not
measurable by spirometry?

The volume that remains in the lungs after maximal expiration and
Obstructive Respiratory Defect - sigmoid curve (hard expiration)
cannot be measured by spirometry is residual volume (RV). The
Restrictive Respiratory Defects - similar as normal but small flow
other lung volumes that are not measurable by spirometry are
volume loop (minimal inhalation)

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Functional residual capacity (FRC) and total lung capacity
(TLC) because they already contain residual volume.
3. Define and differentiate anatomic dead space, alveolar dead
space and physiologic dead space?
Alveolar dead space is sum of the volumes of those alveoli which
have little or no blood flowing through their adjacent pulmonary
capillaries. An example is an alveolus that is ventilated but not
perfused, as a result, no gas exchange can occur. Alveolar dead space
is negligible in healthy individuals but can increase dramatically in
some lung diseases due to ventilation perfusion mismatch.
Anatomical dead space is the volume of the conducting airways
(150-250mL). It is the portion of the airways which conducts gas to
alveoli. No gas exchange is possible in the spaces. In healthy lungs
where the alveolar dead space is small, anatomical dead space is
constant regardless of circulation.
Physiological dead space is the part of the tidal volume which does
not participate in gas exchange.
III. MEASUREMENT OF PEAK EXPIRATORY FLOW
RATE
1. What is peak expiratory flow rate?
Peak expiratory flow rate or PEFR is greatest flow rate achieved
during the expiratory maneuver. This is among the three main
pulmonary function tests in creating a flow-volume loop; the other two
includes the FVC and expiratory flow rates.
2. Discuss the advantage of PEFR monitoring and mention
clinical conditions where it is useful?
Measuring the maximum speed expiration of the patient is important
for the physician to monitor and determine the functionality of the
lungs, severity of asthma symptoms. This can also be used for creating
asthma management plans. This is used to distinguish the condition of
the patient based on the result; if the peak flow is high the patient is
well on the other hand when the patient has low reading it is indicated
that his airways are constricted.
According to the American Lung Association, peak flow readings are
classified into 3 zones. The green zone indicates respiratory is under
good control, yellow zone indicates the respiratory airways are
narrowing and additional medication may be required, red zone
indicates medical emergency, severe airway narrowing and involves
contacting a doctor.
IV. EXAMINATION OF CHEST AND LUNGS
1. What happens to the vibration, percussion note, and breath
sounds if there were:
Percussion Breath
Vibration
note sounds
A. Air in the
Hyperresonance Hyperresonance Diminished
pleural cavity
B. Fluid in
Decreased Dullness Diminished
pleural cavity
C.
Solidification
Increased Dullness Diminished
of lung
segment
2. When do you hear the following adventitious sounds?
a. Wheeze: wheezing denotes airway obstruction such that there is
narrowed passage for air and so on exhalation, a sound is produced.
Airway obstruction diseases such as bronchial asthma, chronic
obstructive pulmonary disease, pertussis, aspiration and laryngeal or
tracheal tumors are the most common causes of wheezing.
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b. Crackles: is also known as “rales” or “crepitation” and is more
commonly heard on inspiration rather than on exhalation. Crackles is
the snapping, rattling or clicking sound heard on auscultation as a
result of fluid build-up in the interstitium or the pleura of the lungs.
Disease states such as congestive heart failure, pleural effusion and
emphysema are the common conditions wherein crackles are heard.
3. What is egophony?
Egophony is a transmitted voice sound generated by the larynx that
causes modification of the voice resembling the “bleating of a goat”
that is heard upon auscultation. Egophony is commonly heard with
patients having pleurisy with effusion.
Clinicians usually elicit the finding by having the patient vocalize the
long vowel “EE” and then listening for the abnormal transformation of
the sound into a loud nasal “AH” (the “AH” sound ranges from the “a”
of the word hat to the “a” of the word cart; this finding is sometimes
called E-to-A change). Although all vowel sounds are altered by the
lung (even healthy lung), what makes egophony distinctive is the
intensity of the change and the suddenness with which it appears over
a small area on one side of the chest. Therefore, before concluding a
patient has egophony, the clinician should confirm that a similar
change of sound is absent over the identical location of the opposite
chest.
V. CASE 1
Nene is a 37-year-old call center agent. She is a known asthmatic
since childhood. She is married to Noynoy who is a heavy smoker with
whom she has 3 children aged 4, 7 and 10. Her maintenance
medications are Salmeterol Fluticasone (Seretide) and Salbutamol MDI
as needed. However, Nene's compliance to Seretide is poor and she
relies only on her Salbutamol inhaler for exacerbations. 3 days ago,
she developed low grade fever, colds and general body malaise. This
was followed by dyspnea and nocturnal wheezing. Patient did not seek
consult but instead self-medicated with salbutamol nebulization. The
condition worsened now with noted chest tightness and dyspnea even
at rest. She was rushed to the emergency room. Initial physical
examination revealed BP 140/90, CR 114/min, RR 32/min with noted
use of accessory muscles of inspiration. Chest and Lung examination
revealed intercostals and subcostal retractions with diffuse wheeze and
tight air entry. ABG revealed the following results: pH of 7.48, pCO2 35
mmHg, HCO3 22, paO2 52mmHg, FiO2 0.21.
Questions:
1. What is the expected spirometry result for Bronchial
Asthma? Based on the patient's spirometry results, what
parameters denote presence of obstructive airway disease?
What parameters denote reversibility? Explain
a) What is the expected spirometry result for Bronchial Asthma
• < 70% FEV₁/FVC
• Reversible
• FEV₁ increased by 12% and 200 ml (after nebulization)
b) Based on the patient's spirometry results, what parameters denote
presence of obstructive airway disease?
• < 70% FEV₁/FVC
• Irreversible: permanent destruction
• FEV₁ does NOT improve by 12% and 200 ml (after
nebulization)
• No period of normalcy
• Destruction of airways due to cigarettes and exposure
to biomass fuels
c) What parameters denote reversibility?
A significant rise in FEV1 is diagnostic for asthma, which is reversible,
after the intake of bronchodilator like Salbutamol. If FEV1 has not risen
significantly after the intake of the bronchodilator, the obstruction is
likely to be irreversible and caused by abnormality (like COPD) and
other tests will be necessary to make a definite diagnosis.
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2. What lung volumes and capacities are affected in bronchial
asthma? Compare these changes to normal PFT
In bronchial asthma, the airways become narrowed and results
in difficulty in inspiration and expiration. Since the negative
intrathoracic pressure during inspiration aids to maintain the airways
open during inspiration, the impact of the disease is greater during
expiration than during inspiration. This causes trapping of air inside
the lungs causing the residual volume and hence the functional
residual capacity to be increased. The inspiratory reserve volume is
relatively constant, but the expiratory reserve volume tends to
decrease.
Residual Volume Increase
Functional Increase
Residual Capacity
Inspiratory Relatively Constant
Reserve Volume
Expiratory Decrease
Reserve Volume
3. Define “work of breathing”. What are the factors that affect
work of breathing? List and explain all the clinical
manifestations of Nene that shows alteration of the work of
breathing.
Work of breathing is the defined as the work required to overcome
the inherent mechanical properties of the lungs, such as elastic and
force-resistive forces, and to move both the lungs and the thoracic
wall.
● Factors affecting the work of breathing include:
1. Compliance: the ability of the lungs to distend during respiration is
one of the major contributing factors to the work of breathing such
that decreased compliance, in instances such as in fibrosis and
decreased surfactant levels in the lungs, there is increased work of
breathing.
2. Resistance from other tissues, such as in the case of increased
pulmonary venous pressure due to drowning, increases the work of
breathing.
3. In disease states, such as bronchial asthma and chronic
obstructive pulmonary disease where there is increased oxygen
demand but decreased oxygen supply, the work of breathing increases
so as to compensate for the low oxygen levels in the blood and in the
tissues.
● Manifestations of the patient:
1. Nocturnal wheezing: bronchoconstriction brought about by her
bronchial asthma, decreases the diameter of the passageway for air
flow thus creating a sound upon exhalation.
2. Tachypnea: increase in the respiratory rate is the body’s response
to decreased oxygen levels in the body such that the lungs
compensate by increasing the frequency of respiration so as to meet
the oxygen demand.
3. Dyspnea and chest pain: the primary muscles of respiration
would be overused and therefore exhaust causing pain and difficulty of
breathing. This would then trigger the body to recruit accessory
muscles of respiration so as to help in the ventilation.
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4. Interpret initial ABG results. Explain the reason behind the
abnormality. What abnormality should be the foremost
consideration in making corrections?
PARAMETER ABG RESULTS NORMAL INTERPRETATION
VALUES
pH 7.48 7.35-7.45 High
pCO2 35 mmHg 35-45 Normal
mmHg
paO2 52 mmHg 80-100 Low
mmHg
HCO3 22 meq/L 22-26 meq/L Normal
The result of the patient’s ABG would conclude respiratory alkalosis,
uncompensated with hypoxemia.
Bronchoconstriction caused by the bronchial asthma of the patient
limits the oxygen levels in the blood thus also limiting the oxygen
supply to the tissues. This would result to the compensatory response
which is to increase the respiratory rate so as to increase also the
oxygen supply. However, hyperventilation would increase the excretion
of CO2 thus decreasing the pCO2 levels of the patient and eventually
leading to increased pH due to decreased carbonic acid generation and
relatively increased bicarbonate levels.
The decreased pCO2 should be addressed first so at to bring back the
other values to normal which is necessary for optimum oxygenation.
Breathing into a paper bag during acute attacks limits the escape of
CO2 and allows re-inhalation of it back to the lungs. Returning the
pCO2 back to its normal value would then allow carbonic acid
generation through the enzyme carbonic anhydrase found in the lungs
thus decreasing the pH back to its normal value.
VI. CASE 2
1.What is the most likely predisposing factor to Noynoy’s
condition? Explain how this leads to his present illness.
Noynoy has been a smoker since he was 15 years old, thus we can
identify smoking as the major predisposing factor in his condition. The
accumulation of the components of a cigarette, specifically nicotine
and carbon dioxide, in the respiratory epithelium adversely affects the
sweeping (of foreign particles) function of the epithelium that serves to
clear and protect the airways. This will then cause irritation and will
manifest as cough. In cases of chronic irritation the respiratory
epithelium is converted into a stratified squamous epithelium through
the process of metastatic metaplasia. The dyspnea experienced by
Noynoy can be attributed to the large air pockets (bullae) formed
due to the severe destruction of small airways. These bullae replace
the lung tissues. The breakdown of the lung tissue (emphysema)
results to a poor airflow and small airway disease known as
obstructive bronchiolitis, causing his inability to breathe out air
fully. His lethargy and drowsiness may be attributed to the
resulting little amount of oxygen and high amount of carbon
dioxide that entered his brain.
2. Interpret the spirometry results of Noynoy. What are the
criteria for diagnosing his disease? Differentiate this from a
spirometry of a bronchial asthma patient like Nene.
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The spirometry results of Noynoy are noted to be significantly
diminished. The diminished FEV1 indicates that there is an increased
airway resistance to expiratory flow. The low FVC, on the other hand,
denotes that there is a premature closure of airway during expiration.
The following are the criteria for diagnosing his disease:
● FORCED VITAL CAPACITY (FVC)- The most basic maneuver in
spirometry; volume of air that can forcibly be blown out after full
inspiration.
● FORCED EXPIRATORY VOLUME IN 1 SECOND (FEV1) - The
volume of air that can forcibly be blown out in one second, after full
inspiration.
● FEV1/FVC ratio (FEV1%)- The ratio of FEV1 to FVC.
○ Healthy adults: approximately 70–85% (declining with age)
○ In obstructive diseases (asthma, COPD, chronic bronchitis,
emphysema):
■ FEV1 (<80%, often ~45%) diminished because of
increased airway resistance to expiratory flow.
■ FVC may be decreased as well, due to the premature
closure of airway in expiration, just not as diminished as FEV1. This
generates a reduced value (<80%, often ~45%).
○ In restrictive diseases (such as pulmonary fibrosis): FEV1 and
FVC both reduced proportionally, and the value may be normal or
even increased as a result of decreased lung compliance.
● TIDAL VOLUME (TV) - The amount of air normally inhaled or
exhaled at rest (normal quiet respiration).
● TOTAL LUNG CAPACITY (TLC) - The maximum volume of air
present in the lungs after maximal inspiration.
● Asthma is restrictive while COPD is obstructive, however, both
will have low FEV1/FVC which is <70%.
respiratory rate during exercise, result in a progressive increase in
FRC. This phenomenon is called dynamic hyperinflation and is largely
responsible for exercise limitation in COPD.
B. PURSED LIP BREATHING
Ventilatory muscle dysfunction A number of factors contribute to
ventilatory muscle dysfunction in COPD. A major factor is a
consequence of hyperinflation, which limits force generation and
endurance, and places the inspiratory muscles at a mechanical
disadvantage. Other factors include nutritional alterations, a sustained
inflammatory response that affects the contractile apparatus, tissue
hypoxia, and loss of muscle mass.These factors also affect other
skeletal muscles, which may further contribute to exercise limitation
C. NECK VEIN ENGORGEMENT AND BIPEDAL EDEMA
Cardiovascular disturbances Cardiovascular disturbances are
common in COPD and may represent a complication of COPD itself or
may be triggered by the same factor, that is, smoking. Recently it has
been proposed that lung inflammation may directly affect
atherogenesis by driving systemic inflammation. Pulmonary
hypertension is a late complication of COPD and independently
worsens its prognosis. A major factor is chronic hypoxia, which can
result in pulmonary vasoconstriction. Right ventricular dysfunction and
failure (cor pulmonale) may eventually develop and add to the
morbidity and mortality of this disease. This phenomenon will lead to
the increase volume in venous system resulting to neck vein
engorgement and bipedal edema.

3. Draw the MEF of a COPD patient alongside a normal MEF.

Which of the lung volumes and capacities change in COPD
patients?

The respiratory volume of the expiratory flow and total lung

capacity decrease in patients with COPD.

4. Explain the physiologic basis for the following clinical

manifestations of Noynoy .

A. CHRONIC COUGH, PROGRESSIVE DYSPNEA AND

WHEEZING
Airflow limitation and hyperinflation Expiratory airflow
limitation is the principal physiological defect in COPD. Intrinsic airway
factors relate to bronchial wall inflammation and include mucosal
inflammation/edema, bronchial wall remodeling/fibrosis, and increased
mucosal secretions. Extrinsic factors involve the loss of elastic tissue
support for small airways and the dynamic expiratory compression of
these airways. Other factors such as respiratory muscle dysfunction
can further limit airflow in some patients. Hyperinflation can also occur 5. Interpret the ABGs of Noynoy. Explain the decrease in pO2
in COPD, leading to an increase in functional residual capacity (FRC)— and the increase in pCO2. What could have caused his
the amount of air that remains in the lungs at the end of tidal deterioration? Why was there a change in Noynoy’s
exhalation. This can lead to gas trapping and an increase in residual sensorium? How will the abnormality in the blood gas alter
volume (RV). As a consequence, there is an augmentation of the the delivery of O2 to the tissue?
inspiratory work of breathing, which is an important factor in
producing dyspnea. As the expiratory time is essential for lung
Noynoy’s ABG Result
emptying, factors that decrease this time, such as an increasing

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On 2 hours 12 hours after
Admission after
pH 7.32 7.28 7.10
pCO2 48 mmHg 54 mmHg 68 mmHg
HCO3 26 28 30
pO2 56 mmHg 92 mmHg 81 mmHg
FiO2 21% 40% 40%
The patient is in respiratory acidosis. There is gradual increase in
pCO2 and decrease in pO2 levels. An increase in pCOs is an
indication that it is “respiratory” instead of “metabolic”. Due to the
destruction of bronchial walls or accumulation of sputum, there is
insufficient oxygenation process, increasing the CO2 accumulation and
decreasing the O2 supply. Increase CO2 results to hypercapnia and
hypoxemia, resulting to decrease delivery of O2 to the tissues. Acidic
blood decreases the affinity of O2 to blood.
Mechanisms of hypoventilation in COPD:
● Decreased responsiveness to hypoxia and hypercapnia
● Increased ventilation-perfusion mismatch leading to increased dead
space ventilation
● Decreased diaphragmatic function due to fatigue and hyperinflation
VII. CASE 3
1. What are the factors that predisposed to Nini’s condition?
Explain the mechanism behind its occurrence
Nini most likely developed her condition from inhaling asbestos
while washing the clothes of someone who works with asbestos.
Mesothelioma is a type of cancer that develops from the thin layer of
tissue that covers many internal organs. The predisposing factor to
mesothelioma is asbestos, as 80% of the patients have known
exposure to it works with places that contains asbestos, so those who
are working with asbestos is at risk. Other contributing factors for
mesothelioma include inhalation of talc, restrictive lung disease,
excessive sedation, chronic obstructive pulmonary disease,
genetics and infection with the simian virus.
2. Why is the dyspnea worse during exertion? What factors
are affected that caused the increase in the work of
breathing?
The dyspnea is worse during exertion because of asbestos
in which 80% of the cause of mesothelioma, is pleural thickening,
often manifested as discrete pleural plaques, Visceral pleural
thickening often includes blunting of the costophrenic angle and
extends diffusely up the chest wall, if advanced, visceral pleural
thickening is associated with dyspnea.
3. Interpret the ABG results. Explain the difference in finding
pre and post exercise. How does her ABG results differ from
that of Noynoy?
Nini has a difficulty breathing as interpreted in her ABG result due to
her mesothelioma, rare aggreasive form of cancer in the lining if the
lungs and abdomen or heart and interstitial pulmonary fibrosis.
Her ABG results are:
a. pH = 7.46-7.60 which is above normal that is 7.4 thus she is
experiencing alkalemia
b. pCO2 = 32-28 which is very low from the normal that is 40
c. fiO2 = are within the normal range
d. HCO3 = 13-17 which is going high to compensate the low amount
of CO2
Nini and Noynoy differs in their pH, pCO2, HCO3 and fiO2. Nini has
high (alkalosis) while Noynoy has low (Acidosis). Nini’s pCO2 is low
while Noynoy has high. Their HCO3 differs in that Nini has low
PHYSIOLOGY LABORATORY
constantly on the other hand Noynoy differs as it became high after 2-
12 hours of admission. Nini’s fiO2 is normal throughout the test while
Noynoy became high 2-12 hours after admission.
2. What is the expected PFT result for Nini? Draw the MEF of a
patient with pulmonary fibrosis compared to normal and
COPD patient. What other lung function tests may be used to
confirm the diagnosis? Explain the mechanism behind the
examination.
Nini has both obstructive and restrictive pulmonary disorder
Other lung function tests are lung volume determination,
pulse oximetry, PEFR, Diffusing capacity of lung for Carbon
monoxide, assessment of respiratory muscle strength.
The lung tests would request the patient to facilitate maneuvers like
inhaling, forceful inhaling and remaining lung volume after exhaling
can be performed by the patient to evaluate the condition and function
of the lungs.
CHECKPOINT!
1. a basic pulmonary function test which measures the amount of
air inspired and expired
2. Normal physiologic pH
3. A type of cancer that develops from thin layer of tissue that
covers many internal organs and can be caused by inhaling
asbestos
4. a space that is the part of the tidal volume which does not
participate in gas exchange.
5. Shape of flow volume loop of patients with obstructive lung
disease
6. What happens to FRC and ERV when a person lies supine from
a standing position?
7. the volume remaining in the lungs after maximal expiration
8. volumes that are not measurable by spirometry
9. a transmitted voice sound generated by the larynx that causes
modification of the voice resembling the “bleating of a goat”
10. Expected spirometry result for Bronchial Asthma
T/F
11. In bronchial asthma, the airways become narrowed and results
in difficulty in inspiration but not in expiration.
12. Alveolar dead space is the volume of the conducting airways.
It is the portion of the airways which conducts gas to alveoli.
13. Restrictive Respiratory Defects results in flow volume loop is
similar as normal but small flow volume loop due to minimal
inhalation.
Interpret:
14. pH=7.48 pCO2=35 mmHg paO2=52 mmHg HCO3=22 meQ/L
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1. Spirometry
2. 7.4
3. mesothelioma
4. Physiologic dead space
5. sigmoid curve
6. decrease, decrease
7. residual volume
8. TLC, FRC
9. egophony
10. < 70% FEV₁/FVC, Reversible, FEV₁ increased by 12% and 200
ml (after nebulization)
11. F (difficulty in inspiration and expiration)
12. F (Anatomic dead space)
13. T
14. Respiratory alkalosis, uncompensated with hypoxemia

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