Deranged Physiology » CICM Primary Exam » Required Reading » Respiratory system

Static, dynamic and specific compliance

is chapter is most relevant to Section F3(ii) from the 2017 CICM Primary Syllabus, which expects the exam candidates to be able to "define compliance (static,
dynamic and specific)". is has been a popular topic for SAQs:

estion 17 from the second paper of 2019

estion 14 from the first paper of 2016
estion 15 from the first paper of 2014
estion 7 from the second paper of 2011
estion 1(p.2) from the second paper of 2008
Most of these SAQs ask for a definition of compliance, as well as methods of measuring compliance. estion 14 from 2016 and estion 1(p.2) from the second paper
of 2008 also asked for factors which affect compliance. ough it was not specifically asked for, the distinction between static and dynamic compliance seems to be an
expected feature of a high-scoring definition, according to the examiner comments. Specific compliance has never been mentioned in any of the questions and appears
to be absent from the vivas, or what lile we know of them.

In summary:

Respiratory compliance is defined as the change in lung volume per unit change in transmural pressure gradient. It is usually about 100ml/cm H2O.
Static compliance is defined as the change in lung volume per unit change in pressure in the absence of flow. It is composed of:
Chest wall compliance (usually 200ml/cm H2O.
Lung tissue compliance (also usually cm H2O.)
Dynamic compliance is defined as the change in lung volume per unit change in pressure in the presence of flow. Its components are
Chest wall compliance
Lung tissue compliance
Airway resistance (which makes it frequency-dependent)
Frequency dependence of fynamic compliance is due to
Pressue contribution from airway resistance
Preferential distribution of flow into lung units with shorter time constants, a tendency which increases with shorter inspiratory times and increasing
respiratory rates
Specific compliance is compliance that is normalized by a lung volume, usually FRC. It is used to compare compliance between lungs of different volumes (eg. child
and adult)
Hysteresis is the term used to describe the difference between inspiratory and expiratory compliance. Lung volume at any given pressure during inhalation is less
than the lung volume at any given pressure during exhalation. 
Hysteresis is present in both static and dynamic lung compliance curves
Hysteresis develops due to:
e effect of surfactant
Relaxation of lung tissue
Recruitment and derecruitment of alveoli
Gas absrption during measurement
Differences in expiratory and inspiratory air flow (for dynamic compliance)
 
Factors which affect compliance can be divided into chest wall factors and lung factors:

Factors which Affect Respiratory Compliance

Lung compliance Chest wall compliance

Increased  lung compliance Increased chest wall complance

Lung surfactant Ehler-Dahlos syndrome and other connective tissue diseases associated with
Lung volume: compliance is at its highest at FRC increased connective tissue elasticity
Posture (supine, upright) Rib resection
Loss of lung conective tissue associated with age Cachexia
Emphysema Flail segment rib fractures
Open chest (eg clamshell)

Decreased static lung compliance Decreased chest wall compliance

Loss of surfactant (eg. ARDS) Structural abnormalities

Decreased lung elasticity
Kyphosis / scoliosis
Pulmonary fibrosis Pectus excavatum
Pulmonary oedema Circumferential burns
Decreased functional lung volume Surgical rib fixation
Functional abnormalities
Pneumonectomy or lobectomy
Pneumonia Muscle spasm, eg. seizure or tetanus
Atelectasis Extrathoracic influences on chest/diaphragmatic excursion
Small stature
Obesity
Alveolar derecruitment
Abdominal compartment syndrome
Alveolar overdistension
Prone position
Decreased dynamic lung compliance

Increased airway resistance (eg. asthma)

Increased air flow (increased resp rate)

In terms of published peer-reviewed resources, none is beer than Sco Harris' article from 2005. It is available for free from Respiratory Care. It would be easy to stick
with this free article as one's main source of information. e compliance section from Nunn's (p.29-31 of the 8th edition) is also worth reading, but does not contain
any reference to specific compliance (not that it's ever come up in the wrien papers). 

Definition of lung compliance

 e 8th edition of Nunn's gives the following definition of lung compliance (p. 17):

"Lung compliance is defined as the change in lung volume per unit change in transmural pressure gradient (i.e. between the alveolus and pleural space)."

is closely resembles any other definition of lung compliance. For example, Guyton & Hall (13th ed) define it as "the extent to which the lungs will expand for each
unit increase in transpulmonary pressure (if enough time is allowed to reach equilibrium)", which sounds like they were defining static compliance.  For the most
basic form, one may look to Levitzky's Pulmonary Physiology (8th ed.) which simply states that "compliance is defined as the change in volume divided by the change
in pressure".  For the purposes of abbreviating this concept even further to cut precious seconds from the answer writing time:

Compliance = ΔV / ΔP

Static compliance

Static compliance has been defined variably by many authors, but most of the definitions have a single common focus on the absence of flow and the time allowed for
the mobile elements of the respiratory system to relax and come to rest. "A static P-V curve eliminates the resistive and impedance effects on pressure", explains Harris
(2005); what's le, supposedly, is just the compliance of the lung, the unadulterated pressure-volume relationship. Borrowing and slightly modifying a definition from
Miller's Anesthesia:

Static compliance is change in volume divided by change in pressure, measured in the absence of gas flow.

A definition like this suggests that to measure static compliance, all you need to do is stop the gas flow. In reality, this is usually not true. Say you are measuring
compliance. e moment you close the respiratory circuit aer inspiration, you will note a pressure drop which is due to the gas redistributing between lung units with
different time-constants. Surely, you'd say, this is not a "static" process, and choose to wait some seconds before recording the measurement. However, as the seconds
pass, you may note that the measured volume of the lung decreases. is is due to the fact that the gas contained within is being absorbed into the pulmonary
circulation. erefore, in the living human organism, there is never going to be a situation where a truly static pressure-volume relationship can be recorded, and Harris
(2005) recommends the term "quasi-static" to describe them. 

In terms of exam relevance, apart from the abovestated definition, one may safely expect to be asked to draw a diagram to represent the pressure and volume
relationhsip of the human lung. If so, one could do worse than reproduce the famous relationship described by Rahn et al in 1946, which was for some reason the first of
such efforts. "It is remarkable that physiologists have paid so little attention in the past to the mechanics of breathing that no adequate data are now on record
concerning the pressure-volume characteristics of the chest and lungs in normal men", the authors complained.  ey acquired normal men, occluded their nostrils
with cork stoppers, and measured their airway pressures at different fractions of their vital capacity (the subjects exhaled fully and then inspired a known volume of
gas from the spirometer before performing a breath hold). With these manoeuvres, the following relationship was demonstrated:

e diagram above is identical to Figure 6 from the original paper, but it was gentrified slightly to modernise it for consumption by modern readers (nobody calls that
volume "residual air" any more). It demonstrates the classical lung compliance curve, where the compliance is poor at low and high volumes, but optimal just above the
FRC, i.e. in the range of the normal tidal volume.
Components of static compliance

Obviously, when you pump gas into a person's chest, the pressure-volume relationship is going to be a complex combination of several factors. Of these, the dominant
players will be the chest wall and the tissues of the lung itself. When asked to desribe this concept, a CICM trainee would likely be expected to regurgitate this
equation:

Where, predictably,  CRS is the compliance of the respiratory system as a whole, CL is the compliance of the lung and CCW is the compliance of the chest wall. Usually,
textbooks give normal values for these compliances; for the lung and chest wall, these are 200ml/cm H2O. 

e compliance of the lungs and chest wall are related to the elastic properties of these structures, which are discussed in a chapter all of their own.

Hysteresis in static lung compliance

Under normal conditions (i.e where it is not filled with saline), the lung does not behave as an ideal system, i.e. the energy invested in its distension is not returned
upon deflation. e upshot of this is that inflation and deflation have different pressure-volume relationships, and the difference between them is called "hysteresis", a
term etymologically related to "lag" or shortcoming" which describes the dependence of a system's state upon its history. If one were completely unprepared for the
questions "define hysteresis", one could easily break down and blather something like "the inspratory thing does not look like the expiratory thing", so it would
probably be worth investing some time in memorising a more solid definition. Here's one from an excellent article by Escolar & Escolar (2004):

"The energy applied to the lung in inspiration is not recovered in expiration. The property of dissipating energy receives the name of hysteresis."

A pithier, more memorable definition is available from a much less reputable source:

"Lung volume at any given pressure during inhalation is less than the lung volume at any given pressure during exhalation"

It makes logical sense to expect something like this in a dynamic PV loop because of the effects of resistance (more on that later),  but it is seen even in static
compliance measurements.  Here, a diagram from Harris (2004) demonstrates the hysteresis in a static PV loop using the supersyringe method. e added labels
demonstrate that, for the same change in pressure, the expiratory compliance is lower:

hysteresis curve with explanatory labels

Why does this happen? ere are four main reasons. 

Recruitment and derecruitment: Collapsed alveoli have walls which are stuck together and which require added mechanical energy to open. In contrast, well-
inflated alveoli are relatively elastic and require relatively lile energy to inflate further. Because of this, the pressure-volume relationship of alveoli changes
aer they have been fully inflated. 
e effect of alveolar surface tension: surface tension in a deflated lung is lower than in a fully inflated lung because the molecules of alveolar surfactant are
packed closer together, increasing their concentration at the gas-liquid intereface and thereby decreasing surface tension. ese phospholipid molecules on
the surface of well-stretched alveoli are further apart, which increases the surface tension and makes the lung less compliant.  us, aer fully inflating the
lung, the deflation curve has a lower compliance, i.e. there is lile change in volume over a substantial change in pressure
Stress relaxation refers to the loss of energy in the lung parenchyma which occurs with stretch. is resembles the classical definition of hysteresis, as the
quantity of unrecovered energy which results from something being imperfectly elastic. e imperfect lung stretches, consumes energy, and then wastes it on
changing the shape of its collagen and elastin fibres instead of storing it for later release. 
Gas absorption during measurement is not really a property of the lung parenchyma itself but rather an artifact of measurement. As mentioned above,
measurement of static lung compliance has a certain built-in pause in every step, which allows some of the gas to become absorbed in living systems, leading
to an apparent change in volume and pressure.

Dynamic compliance

In contrast to static compliance, the term "dynamic compliance" sounds like it refers to something vigorous and mobile. e definition of static compliance is easily
repurposed to suit:

Dynamic compliance is change in volume divided by change in pressure, measured in the presence of gas flow.

In essence, it is the same compliance but measured during normal inspiration and expiration. Dynamic compliance is always lower than static compliance. e reason
for this is that dynamic compliance, in addition to the usual chest wall pressure and lung pressure,  also incorporates airflow resistance.

is is the main difference between static and dynamic compliance. ere is airway resistance which increases the pressure at every volume, and this depends on the
gas flow rate.  Resistance increases with increasing airflow, especially as the flow turns turbulent. As such, the contribution of airway resistance to dynamic compliance
increases as airflow increases, which in turn decreases compliance.
Another major difference between static and dynamic compliance is the lack of an equilibration pause at the time of measurement. With the static compliance
measurement methods, one usually measures a lung when it is completely still, aer a few seconds have allowed units with longer time-constants to become completely
filled. Measurement of dynamic compliance happens on the fly, and there is no time for air to distribute to those slower lung units. e consequence of this is a higher
pressure measured for unit volume, i.e. a lower lung compliance. Moreover, the shorter the inspiratory and expiratory time, the more this effect will influence dynamic
compliance.

So. Dynamic compliance decreases with increasing airflow and a faster respiratory cycle. Both of these are present in tachypnoeic patients. e term typically used to
describe this is "frequency dependence".  Katsoulis et al (2016) demonstrated this beautifully in a group of asthmatic patients. eir graph (shamelessly stolen from the
original paper) demonstrates the widening gap between static and dynamic compliance associated with increasing respiratory rate, particularly where there is small
airways disease. 

Apart from the abovementioned contribution of respiratory resistance to the total airway pressure here, dynamic compliance is also affected by the heterogeneity of
time constants among lung units. A rapid inspiration will only have time to fill the "fast" alveoli, thereby generating pressure on the basis of the compliance of a
relatively slow volume (the rest of the volume being "slow" alveoli). is will also add to the frequency dependence of dynamic compliance.

Now, at this stage it is also important (though probably not relevant for exam purposes) to point out that in fact the definition of dynamic compliance used here (and in
many other resources) is not entirely accurate. Even though that is what the examiners want you to think, the inclusion of resistance in the definition makes dynamic
compliance something of a misnomer. Or rather, it would be more accurate to say that the equation,

Cdyn = VT / (PIP - PEEP)

where

VT is the tidal volume

PIP is the peak inspiratory pressure
PEEP is the positive end-expiratory pressure

does not measure a compliance of any sort, because resistance is included in the measurement.

Moreover, in any case the measurement of dynamic compliance which is usually performed by the mechanical ventilator during routine function is determined from
constructing a pressure-volume loop during ventilation. at loop allows the ventilator to determine where the gas flow is zero, i.e. where the airway pressure and
alveolar pressure is equal. e gradient of the line connecting these points is the dynamic compliance. e point of zero gas flow, however, is usually not the peak
inspiratory pressure, but something closer to P1, the drop in pressure which occurs at the end of inspiration:
 us, in a mechanically ventilated patient, the Cdyn is calculated as:

Cdyn = VT / (P1 - PEEP)

where

VT is the tidal volume

P1 is the pressure shortly aer cessation of flow, which is slightly higher than the plateau pressure which would give you dynamic compliance
PEEP is the positive end-expiratory pressure

Specific compliance

e need for the concept of specific compliance can be demonstrated by a simple thought experiment. Consider the pressure-volume relationship of a 20kg child. One
might achieve vital capacity of perhaps 1L,  at 20 cm H2O. Compare it to an adult, whose lung volume at 20 cm H2O might be 4L.  Does this mean that the adult has
higher lung compliance?

Of course, it does not. However, this demonstrates that the standard method of comparing lung compliance numbers tends to break down when one tries to compare
compliance between patients who are comically mismatched in size. is is where specific compliance comes in. According to Harris (2005),

"Specific compliance is compliance that is normalized by a lung volume"

at normalising lung volume is usually the FRC. us, specific compliance can be expressed as:
 where CTot is the total static lung compliance, and FRC can be substituted with any lung volume.  Because the chosen lung volume also scales with body size, this
parameter should remain consistent irrespective of whether one is big or small. Consider: the child with their lung compliance of 50ml/cmH2O and an FRC of 500ml
would have a specific compliance of  50/500 = 0.1 ml/cmH2O . e large adult, with their compliance of 200ml/cmH2O and a larger FRC of 2000ml, would also have a
specific compliance of 0.1 ml/cmH2O.  e normal value for this is usually given as 0.05ml/cmH2O.

Factors which influence lung compliance

estion 14 from 2016 and estion 1(p.2) from the second paper of 2008 asked about the factors which affect compliance. Particularly the question from 2008 was the
one with the best model answer, which clearly stated what the examiners' expectations were. In summary, these factors are:

Lung volume (affected by PEEP, dynamic hyperinflation, etc)

Lung elastic recoil (affected by age and disease states, eg. emphysema reduces it)
Chest wall compliance (affected by chest injuries, burns, surgery, eg. open chest)
Pulmonary blood volume (a congested lug is less compliant)
Dynamic lung compliance is also affected by the respiratory rate
Lung surfactant increases lung compliance
Posture (see the chapter on the effects of positioning on the mechanics of breathing)
e effects of respiratory rate on dynamic compliance have been discussed already; the effects of surfactant are worth discussing separately.

e influence of alveolar surfactant on lung compliance

Most textbooks find a way to fit lung surfactant into the category of things which affect static compliance. Usually, a graph is troed out which demonstrates the effect
an absence of surfactant has on the compliance of the lung. e reference for this is usually a famous 1971 paper by T.E. Morgan, but in fact the original experimental
data weres published in 1929 by Kurt von Neergaard. Unfortunately, the original article from Zeitschri fur die gesamte experimentelle Medizin can no longer be
obtained by any reasonable (cheap) means, but the graph is sufficiently famous that one can find a version of it everywhere.  In some cases,  for example the diagram
below from Radford (1964), one can even find the original experimental cat's serial number. For some reason, everybody always picks the graph from Cat 27.

static compliance with and without surfactant, from Radford (1964)

Cat 27's lungs were first inflated and deflated with air. en, they were submerged in saline and inflated with saline. e effect was substantial. In the saline-filled lung,
the effect of the surfactant on the surface tension of the alveoli was obliterated, and only the elasticity of the lung itself was measured. e drowned lung was much
more compliant than the air-filled lung. 

However, this seems like an irrelevant diagram at this point. All it describes is that the presence of surface tension decreases lung compliance, and that without it the
compliance of the lung tissue itself is excellent. It is well known that surfactant increases lung compliance, because water on its own has a surface tension so high that
the alveoli would collapse en masse and lung compliance would be extremely poor. Surely, it would be beer to illustrate this concept? A suitable diagram for this
purpose comes from a paper by Lachmann et al (1980). e authors lavaged all the surfactant out of the lungs of rabbits, and thereby created conditions resembling
ARDS (see their stolen graphs below).

compliance of normal and lavaged lung (Lachmann et al, 1980)

Previous chapter: e expiratory and inspiratory process

Next chapter: Measurement of respiratory compliance

References

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