Question: what will happen if there is too
much carbon dioxide in the body?
Answer: Build-up of carbon dioxide can  the blood.
damage the tissues and organs and further impair
oxygenation of blood and, as a result, slow
oxygen delivery to the tissues. Acute respiratory
failure happens quickly and
without much warning.
PHYSIOLOGY OF THE RESPIRATORY
SYSTEM
The cells of the body derive the energy they
need from the oxidation of carbohydrate, fats
and proteins. This process requires oxygen. Vital
tissues like the brain and the heart cannot
survive long without a continuous supply of
oxygen. As a result of oxidation, carbon dioxide
is produced and must be removed from the cells
to prevent the build up of acid waste products.
The respiratory system performs this function by
facilitating life sustaining processes such as
oxygen transport, respiration, ventilation and gas
exchange.
RESPIRATION- The goal of respiration is to
provide oxygen to tissues and to remove carbon
dioxide. The physiology of respiration
processes: 1. Ventilation- the movement of air
the atmosphere and in the alveoli, (2) Diffusion
of O2 and Co2 between the pulmonary
capillaries and the alveoli; and 3. Transport of
O2 and CO2 in the blood.
After these tissue capillary exchanges, blood
enters the systemic venous circulation and
travels to the pulmonary circulation. The oxygen
concentration in blood within the capillaries of
the lungs is lower than that in the lungs’ alveoli.
Because of this concentration gradient, oxygen
diffuses from the alveoli to the blood. Carbon
dioxide, which has a higher concentration in the
blood than in the alveoli, diffuses from the blood
into the alveoli. Movement of air in and out of
the airways continually reloads the oxygen and
removes the CO2 from the airways and the
lungs. This process of gas exchange between the
atmospheric air and the blood and between the
blood and cells of the body is call respiration.
 EXTERNAL RESPIRATION, which is
the exchange of gases (oxygen and
carbon dioxide) between inhaled air and
 INTERNAL RESPIRATION, which is
the exchange of gases between the blood
and tissue fluids.
TYPES OF PRESSURE INVOLVE IN
RESPIRATION
With respect to breathing, three types of
pressure are important.
1. Atmospheric pressure- the pressure of
the air around us. At sea level,
atmospheric pressure is 750 mmHG. At
high altitudes, atmospheric pressure is
low.
2. Intrapleural pressure.
 Pressure within the pleural space
between the parietal and visceral
pleura.
 Intrapleural pressure is always Slightly
below than Atmospheric Pressure and is
called negative pressure, it creates a
suction that holds the lungs open to
their resting level.
 Without this negative pressure to hold
the lungs against the chest wall, the
elastic recoil properties of the lungs
would cause them to collapse.
3. Intra-pulmonic pressure/Intra-
alveolar pressure - the pressure within
the bronchial tree and alveoli. This
pressure fluctuates below and above
atmospheric pressure during each cycle
of breathing.
4. Transpulmonary Pressure- the
difference between intra-alveolar and
intra-pleural pressure
5. Intrathroracic pressure – the pressure
within the entire thoracic cavity.
3 PROCESSES OF RESPIRATION
1. VENTILATION
 refers to the movement of gases in and
out of the lungs. (The exchange of air
between the lungs and the atmosphere
so that oxygen can be exchanged for
carbon dioxide in the alveoli)
 commonly referred to as breathing.
 Ventilation is needed to provide
oxygen for metabolism and to dilute
metabolic pollutants (carbon dioxide and
odour)
 It is the process of air flowing into
the lungs during inspiration
(inhalation) and out of the lungs
during expiration (exhalation). Air
flows because of pressure differences
between the atmosphere and the
gases inside the lungs.
 This requires movement of the walls
of the thoracic cage and of its floor.
The effect of these movements is
alternately to increase and decrease
the capacity of the chest.
Phases of Ventilation
Inhalation (Inspiration)
 Air gases flow into the lungs or the
process of air flowing into the lungs
 Breathing in, voluntary phase.
 The rib cage elevated as intercostal
muscles contract
 The size of the thoracic cavity increases
 (External air is pulled into the lungs
due to an increase in intrapulmonary
volume)
 During the inspiration as the
diaphragm and intercostal muscles
contracts, moves downward, and
expands the chest cavity from top to
bottom. When the capacity of the
chest is increased. Air enters through
the nose, pharynx, larynx, trachea
(inspiration) and moves into the
bronchi, bronchioles and alveoli and
inflates the lungs.
 As the chest expanded, the parietal
pleura expands with it. Intrapleural
pressure becomes negative and
intra-pulmonic becomes more
negative and falls below atmospheric
pressure, and air enters the nose and
travels through respiratory passages
to the alveoli. Entry of air continuous
until intra-pulmonic pressure is equal
to atmospheric pressure; this is
Normal Inhalation. Inhalation can
be continued beyond normal, that is
deep breathing. This requires more
forceful contraction of the
respiratory muscles to further expand
the lungs, permitting more air to
enter.
 The inspiratory phase of respiration
normally active because it requires
energy.
Exhalation (Expiration)
 The air leaves the lungs/ Air gases flow
out the lungs the muscles are relax
 Breathing out, involuntary phase.
 The ribs depressed as external muscles
relaxed
 Diaphragm moves superiorly during
relaxation
 the diaphragm and external intercostal
muscles relax. As the chest cavity
becomes smaller, the lungs recoil and
force the air out through the bronchi
and the trachea.
 As the intra-pulmonic pressure becomes
positive or rises above atmospheric
pressure, air is force out of the lungs
until the two pressures are again equal.
  Forced expiration can occur mostly
by contracting internal intercostal
muscles to depress the rib cage
 the expiratory phase of the
respiration is normally passive,
requiring very little energy.
Inhalation and expiration is brought by the
nervous system and your respiratory muscles.
What is the difference between ventilation
and respiration?
Answer: Ventilation is the movement of a
volume of gas into and out of the
lungs.  Respiration  is the exchange of
oxygen and carbon dioxide across a
membrane either  in the lungs or at the
cellular level.
What is the difference between ventilation
and oxygenation?
Answer: Ventilation and oxygenation are
distinct but interdependent physiological
processes. While ventilation can be thought of
as the delivery system that presents oxygen‐rich
air to the alveoli, oxygenation is the process of
delivering O2 from the alveoli to the tissues in
order to maintain cellular activity.
What are the types of mechanical ventilation?
Answer:
Positive pressure ventilation: pushes the air
into the lungs.
Negative pressure ventilation: sucks the air
into the lungs by making the chest expand
and contract.
MECHANICS OF VENTILATION
 Physical factors that govern airflow
in and out of the lungs are
collectively referred to as the
mechanics of ventilation and include
Air pressure variances, Resistance
to air flow, and Lung Compliance.
AIR PRESSURE VARIANCES
 Air flows from a higher region of high
pressure to a region of lower pressure.
 During inspiration, movement of the
diaphragm and intercostal muscles
enlarge the thoracic cavity and thereby,
lower the pressure inside the thorax to
a level below that of atmospheric
pressure. As a result, air is drawn
through the trachea and the bronchi into
the alveoli. (
 During EXPIRATION; the diaphragm
relaxes resulting in a decrease in the size
of the thorax cavity. The alveolar
pressure exceeds atmospheric pressure,
and the air flows from the lungs into the
atmosphere.
AIRWAY RESISTANCE
 Resistance is determined by the radius
or size of the airway (which the air is
flowing), as well as by lung volumes
and airflow velocity.
 Any process that changes the bronchial
diameter or width affects airway
resistance and alters the rate of airflow
for a given pressure gradient during
respiration
 With increased resistance, greater than
normal respiratory effort is required to
achieve normal levels of ventilation.
Common phenomena that may alter bronchial
diameter which affects airway resistance:
 Contraction of bronchial smooth
muscle- due to asthma
 Thickening of bronchial mucosa- due to
bronchitis
 Obstruction of airway- due to mucus,
tumour or foreign body
 Loss of lung elasticity-due to
emphysema which is characterized by
connective tissue encircling the airways,
thereby keeping them open during both
inhalation and exhalation.
COMPLIANCE
 Is the elasticity and expandability of
the lungs and thoracic structures/ the
extent to which the lungs expand.
 A measurement of distensibility or how
a tissue is stretched.
 Compliance allows the lung volume to
increase when the difference in pressure
between the atmosphere and the thoracic
cavity causes air to flow in.
 Compliance is determined by examining
the volume-pressure relationship in the
lungs and thorax.
 Compliance is normal (1L/cm H2O) if
the lungs and thorax easily stretch and
distend when pressure is applied.
 Factors that determine lung compliance
are the surface tension of the alveoli,
the connective tissue and water content
of the lungs and the compliance of the
thoracic cavity.
 Lungs is made up of collagen and elastin
fibers. Collagen fibers resist stretching
and make lung inflation difficult,
whereas elastin fibers are easily
stretched and increased the ease of lung
inflation. When elastin fibers are
replaced with scar tissue the lungs
becomes stiff and non-compliant
 The fluid lining the alveoli has a high
surface tension. When the surface
tension is high, the most interior surface
of the alveoli are difficult to separate
from one another and more energy is
required to fill the alveoli with air
during inspiration. A lipoprotein
substance called Surfactant secreted by
type 2 cells decreases the surface tension
of these fluids in the alveoli.
 Surfactant exerts 4 important effects on
lung inflation. 1. It lowers surface
tension, it increases lung compliance
and ease of inflation, it provides stability
and more inflation into the alveoli and
assist in preventing pulmonary edema
by keeping the alveoli dry.
 Without surfactant, lung inflation is very
difficult. The type 2 alveolar cells that
produce surfactant do not mature until
26th to 28th weeks of gestation.
Premature infants do not have sufficient
surfactant leading to alveolar collapse
and severe respiratory distress or IRDS
among infants and ARDS among adults.
 Increased compliance occurs if the
lungs lost their elastic recoil and
become more overdistended (ex:
emphysema)/ it is easier to expand lung
tissue.
 Decreased compliance occurs if the
lungs and thorax are stiff (rigid,
inflexible, firm)/it is more difficult to
expand the lungs. Conditions
associated with decreased compliance
include morbid obesity, pneumothorax,
hemo-thorax, pleural effusion,
pulmonary edema, atelectasis,
pulmonary fibrosis and ARDS.
Decreased compliance requires greater
than normal energy expenditure by the
patient to achieve normal level of
ventilation.
LUNG VOLUMES AND CAPACITIES
 Lung function reflects the mechanics of
ventilation, is viewed in terms of lung
volumes and capacities.
 The flow of air in and out of the lungs
provides tangible measures of lung
volumes although referred to as
pulmonary function.
 Lung volumes are categorized as tidal
volume, IRV, ERV and residual volume
  Lung capacity is evaluated in terms of
vital capacity, inspiratory capacity,
functional residual capacity and total
lung capacity.
LUNG VOLUMES
Tidal Volume
 is the amount of air that moves in and
out of the lung with each normal breath
 The volume of air inhaled and exhaled
with each normal breath
 Normal Value: 500ml or 5-10mL/kg
 Significance: The TV may not vary
even with severe disease
Residual volume
 The amount of air that remains in the
lungs after forceful/maximum
expiration/exhalation.
 It prevents collapse of the lungs
during expiration
 1200ml
 Significance: Residual volume may be
increased with obstructive disease
Inspiratory Reserve Volume (IRV)
 The maximum volume of air that can be
inhaled after a normal inhalation
 Normal value (Brunner 2018) 3000mL
 Usually between 2100 and 3200 ml
Expiratory Reserve Volume (ERV)
 The maximum volume of air that can be
exhaled forcibly after a normal
exhalation
 Normal Value: 1100 ml
 ERV is decreased with restrictive
conditions such as obesity, ascites, and
pregnancy
LUNG CAPACITIES
VITAL CAPACITY/VC
 The maximum volume of air exhaled
from the point of maximum inspiration
(VC= TV+IRV+ ERV)
 Normal value 4600 mL
 A decreased in viatl capacity may found
in neuromuscular disease, atelectasis,
pulmonary edema, COPD and obesity
Inspiratory Capacity
 The maximum volume of air inhaled
after a normal expiration
 IC= TV + IRV
 3500ml
 A decreased in IC may indicate
restrictive disease or obesity
Functional Residual Capacity
 is the amount of air that remains in the
lungs after normal exhalation/expiration.
 FRC= ERV + RV
 FRC may increased with COPD and
decreased in ARDS and obesity
Total Lung Capacity
 The volume of air in the lungs after a
maximum inspiration
 Is the total of all four volumes (RV, TV,
IRV, ERV)
 TLC may decreased with restrictive
disease such as atelectasis and
pneumonia and increased in COPD
Many factors that affect respiratory capacity
 A person’s size
 Sex
 Age
 Physical condition
2. Pulmonary Diffusion
 The process by which the oxygen and
carbon dioxide are exchange from an
area of higher pressure to an area of
lower concentration at the air-blood
interface. The alveolar capillary
membrane is ideal for diffusion because
of its thinnest and large surface area. In
the normal healthy adult, O2 and CO2
travel across the alveolar capillary
membrane without difficulty as a result
of differences in gas concentrations in
the alveoli and capillaries.
  Diffusion of oxygen from the alveoli to
the pulmonary capillaries and diffusion
of CO2 from the pulmonary capillaries
to the alveoli.
 Lung diffusion testing measures how
well the lungs exchange gases. This is
an important part of lung testing,
because the major function of the lungs
is to allow oxygen to "diffuse" or pass
into the blood from the lungs, and to
allow carbon dioxide to "diffuse" from
the blood into the lungs
 CO2 diffuses about 20 times more
rapidly than the O2. There are 4 factors
that affect alveolar-capillary gas
exchange (1) the surface area available
for diffusion, (2)the thickness of the
alveolar-capillary membrane, (3) the
partial pressure of gas across the
membrane, (4) solubility and molecular
characteristics of the gas. Any condition
or disease that affects one or more
factors may impair the diffusion of O2
and CO2 across the alveolar- capillary
membrane.
OXYGEN TRANSPORT
 Oxygen is supplied to, and carbon
dioxide is removed from cells by
way of circulating blood through the
thin walls of the capillaries. Oxygen
diffuses/ distribute from the capillary
through the capillary wall to the
interstitial fluid. At this point, it
diffuses through the membrane of
tissue cells where it is used by
mitochondria for cellular respiration.
 O2 is carried in the blood in two
forms: dissolved in plasma (less than
3%) and attached to hemoglobin
(97%). The partial pressure of
oxygen in arterial blood (PaO2)
represents the level of dissolve
oxygen in plasma. Less than 3% is
carried in this form.
 And 97% of O2 is carried in the
blood bound to hemoglobin is called
Oxyhemoglobin. Oxyhemoglobin is
transported in arterial blood and
made available to tissues for use in
cell metabolism. The saturation of
O2 in arterial blood (SaO2)
represents the percentage of
hemoglobin molecules that are
bound with oxygen.
 The hemoglobin molecule is full
saturated with oxygen to all four of
its oxygen binding sites. The term
AFFINITY refers to the capacity of
the hemoglobin to combine with O2.
 When the affinity is High,
hemoglobin binds readily with
oxygen at the alveolar capillary
membrane. But at the tissue level,
Hemoglobin does not readily
releases the oxygen
 When the affinity is Low,
hemoglobin does not bind with the
oxygen at the alveolar-capillary
membrane. When the affinity is low,
hemoglobin releases oxygen more
readily at the tissue level
CO2 TRANSPORT
 CO2 is carried in the blood in 3
forms: as dissolves CO2-10%, attached
to hemoglobin (30%), and as
bicarbonate (60%)
 CO2 is formed as a metabolic by
product. It diffuses out of the cells and
into the capillaries.
3. Pulmonary Perfusion
 Is the actual blood flow through the
pulmonary vasculature.
 The blood is pump into the lungs by the
right ventricle through the pulmonary
artery.
 The pulmonary artery divides into the
right and left branches to supply both
lungs.
 Pulmonary artery pressure, gravity, and
alveolar pressure determine the patterns
of perfusion.
 The pulmonary circulation is
considered a low pressure system
because the systolic blood pressure in
the pulmonary artery is 20-30mm Hg
and the diastolic pressure is 5-15 mm
Hg. Because of these low pressures, the
pulmonary vasculature normally can
vary its capacity to accommodate the
blood flow it receives. Reduced gas
transfer in patients with pulmonary
arterial hypertension (PAH) is
traditionally attributed to remodeling
and progressive loss of pulmonary
arterial vasculature that results in
decreased capillary blood volume
available for gas exchange
 However, when a person is in upright
position, the pulmonary artery pressure
is not great enough to supply blood to
the apex of the lung against the force of
the gravity. Thus when the person is
upright, the mung may be considered to
be divided into three sections: an upper
part with poor blood supply, the lower
part with maximum blood supply, and a
section between the two with an
intermediate supply of blood. When a
person is lying down turns to one side,
more blood passes to the dependent
lung.
 Perfusion is also influence by alveolar
pressure. The pulmonary capillaries
are sandwich between adjacent alveoli.
If the alveolar pressure is high, the
capillaries are squeezed.
RELATIONSHIP OF VENTILATION TO
PERFUSION
DISTRIBUTION OF VENTILATION
 Not all areas in the lungs have the same
ventilation. Body position affects
distribution of ventilation.
 In a seated or standing position, lower
regions of the lungs better than do upper
zones. In supine position, the apex and
the base of the lungs ventilate about the
same; however, ventilation in the lower
most (posterior) lung is greater than the
uppermost (anterior) lung. In lateral, the
dependent lung is best ventilated.
DISTRIBUTION OF PERFUSION
 The distribution of pulmonary blood
flow is affected by body position and
gravity.
 In Upright position, blood flow is better
at the base that the apex of the lungs.
 In supine position, the blood flow from
apex to base is the same, but blood flow
in the posterior regions exceeds the
anterior regions
 In prone position, blood flow in the
dependent/anterior exceeds the posterior
region.
OXYHEMOGLOBIN DISSOCIATION
CURVE
 Shows the relationship between the
partial pressure 0f oxygen (PaO2) and
the percentage of saturation of oxygen
(SaO2)
 Normal levels-PaO2>70mmHg
 Relatively safe level- PaO2 45-
70mmHG
 Dangerous level-PaO2<40mmHG
 The percentage of saturation can be
affected by CO2, hydrogen ion
 concentration, temperature and 2,3-
diphosphoglycerate.
 An increase in these factors shift the
curve to the right, less oxygen is pick up
in the lungs but more O2 is release to
the tissues if partial pressure of oxygen
is unchanged.
 A decrease in these factors causes the
curve to shift to the left, making the
bond between oxygen and hemoglobin
stronger. If PaO2 is still unchanged,
more oxygen is pick up in the lungs but
less oxygen in tissues.
VENTILATION and PERFUSION
BALANCE and IMBALANCE
Adequate gas exchange depends on adequate
ventilation-perfusion (V/Q) ratio. In different
areas of the lung, the V/Q ratio varies. Airway
blockages, local changes in compliance, gravity
may alter ventilation. Alteration in perfusion
may occur with a change in the pulmonary artery
pressure, alveolar pressure or gravity.
VENTILATION (V)
 the movement of gases in and out of the
lungs. It is the amount of gas or air into
the alveoli ready for gas exchange.
PERFUSION (Q)
 the amount of blood flow to the alveoli
prepared for gas exchange as well.
 the actual blood flow through the
pulmonary vasculature.
V/Q mismatch
 this occurs as a result of inadequate
ventilation, inadequate perfusion or both
 there are four possible V/Q states in the
lung. Normal V/Q ratio, Low V/Q
(Shunt), high V/Q ratio (dead space) and
Absence of ventilation and perfusion
(Silent unit)
Normal V/Q ratio
 in the healthy lung, a given amount of
blood passes an alveolus and is matched
with an equal amount of gas. The ratio is
1:1 (ventilation matches perfusion)
Low Ventilation Perfusion ratio: Shunts
 when perfusion exceeds ventilation, a
shunt exists (B). Blood bypasses the
alveoli without gas exchange occurring.
This is seen with obstruction of the
distal airways such as with Pneumonia,
atelectasis, tumor or mucus plug.
 V/Q imbalances causes shunting of
blood resulting in HYPOXIA (low level
of cellular oxygen). Shunting appears to
be the main cause of hypoxia after
thoracic or abdominal surgery and
respiratory failure.
 Severe hypoxia results when the amount
of shunting exceeds 20%. Supplemental
oxygen may eliminate hypoxia
High Ventilation-Perfusion ratio: Dead Space
(C)
 When ventilation exceeds perfusion,
dead space results
 The alveoli does not have an adequate
blood supply for gas exchange to occur.
This is characteristic of a variety of
disorders including pulmonary emboli,
pulmonary infarction and cardiogenic
shock.
Silent Unit (D)
 Absence of both ventilation and
perfusion or with limited ventilation and
perfusion, a condition known as Silent
unit. This is seen in Pneumothorax, and
severe acute respiratory distress
syndrome.