Professional Documents
Culture Documents
HUMAN
PHYSIOLOGY
FOR MEDICAL STUDENTS
I RESPIRATION I
BY
MAGDI SABRY, MD
professor of physiology
Facu1ty of Medicine
AI-Azhar University
CAIRO
All rights resen•ed, no part tifthis btHJk may be reproduced in any
manner without written permission from the author or publisher.
DEDICATED TO
" \AfW'~'t'~~~~;---l
I.S.U 1\ 977- 19-6475- 5 .)J..UI ~~I
~ ~ :.___j
PRErACE
With recent advances in the field of human physiology, it has become
urgent to provide an up to date review on the subject.
The major part of my gratitude should be given to all who taught me,
and to my wife and children who, patiently, supported me during
preparation of tlti.~ book.
Tlti.\· new edition i.\ original hotlt in <tltape am/ contents. A ll chapter\
lzal't' been extemil·e~r re1·i.\ ed and updatetl Recent datu are added e!H•-
wht're am/many \II hjec:l\ lllll't' ht't'll c:ompll'ft•~•· r ewrillen.
MAGDI SABRY
20()6
CONTENTS )
Cha pter 1 : Th e respiratory .\J'.\'Iem .......... . . ....... ... . ... . ........ . .... I
- Definition and divisions of respiration .. .. .. . .. . .. .. .. .. .. . .. . .. . .. .. .. .. I
- The respiratory system (or apparatus) .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . ..... 2
- F Jnctions of the respiratory system . .. .. .. ........ : ........................ 6
- The respiratory protective mechanisms ...... ................ .......... ...... 7
- l\.letabolic and endocrine functions of the lungs ........ ... ................ 9
- The bronchial tone . . .. . .. .. .. .. .. .. .. . .. .. .. .. . . .. . .. .. .. .. .. .. 9
-Asthma ..... ......................... ..... ........................ ........... 10
- Emphysema and effects of smoking. .. ............. ....... ..... ........... 11
Ct-apter 2 : Th e lung 1•olume\· and capacitie\· .. ......... ... ............ 12
-Measurement of the lung volumes and capacities ............... .... ...... 15
- The respiratory dead space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
- Assessment of pulmonary functions (the pulmonary function tests) . . . 19
- Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Ct' a pter 3 : 1\lechanism (mechllnics) of breathing ... ........ .... ..... .. 2~
- The respiratory centres...... .. .. .. .. . .. . .. .. .. . .. .. .. .. . . .. .. . .. .. . .. .. .. .. 24
-Genesis of the breathing rhythm .............................................. 26
-Mechanism (mechanics) of inspiration .................................... 27
- Mechanism (mechanics) of expiration ... ... .................... .. ......... .. 28
- Intrapulmonary pressure changes during eupnea......... . . . . . . . . . . . . . . . 30
- Bering-Breuer reflexes ....................................................... 30
-Apneustic breathing (apneusis) ..................................... .. ........ 31
- The intrapleural and intrathoracic pressures.. .................... ..... ... 3 1
-The pulmonary surfactant. .. .. ......................................... 33
-The respiratory distress syndrome (RDS) ................................... 33
- Alveolar stability. ............................................................. 34
- Elastic properties of the respiratory system .................... .......... .. 35
-Interaction between the recoil forces of the lungs and chest wall...... 36
- The compliance of the lungs and chest wall. .................. .......... .... 3 7
- The work of breathing........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 40
-Effects of gravity on the lungs ..... .... ...................... ..... .. .......... 42
- P1eumothorax.... ... .............. .. .. . . . .. . .. .. . . . . . .. . . . . . . . .. . . . . . . . . . . . . .. 44
Chapter 4 : Regult1tion (control) of breathing . ... .... .. ......... ... . .. ~5
- Chemical regulation of breathing ..... ................ .. .................... .45
- l\onchemicaJ regulation of breathing..................... . ................. 49
-Effects of muscular exercise on respiration .. . .. .. .. .. .. .. .. .. .. .. .. .. ... 52
- Periodic (Cheyne-Stokes) breathing .................... ....... ...... ........ 55
- Artificial respiration ............ ... ................ ... .... ... . .. ................ 57
CONTENTS (cont.)
Page
Chapter~ : Cios ex.clLllnge UJ the /.ungs ··~u ... - ·•w~ ..- -.. ··- 59
- Some physical laws of gases ....................... . .. ........... ........ 59
-The partial pressure of gases (P) ................... .. ... ......... ........ 59
- Fick, s law of gas diffusion ....... ... ..... ............................. . ... 60
- The alveolo-capiHary membrane .................................... ... ... 61
- Equilibration of respiratory gases in the lungs... ........... ...... .... 62
- The diffusion capacity of the lungs......... ..... ...................... 63
Chapter 6: Oxygen transport (c.arriJJ.ge) by tb£ hloml __... _ 64
- Oxygen in the blood ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 64
- The physiologic shunts... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
- The 02-Hb dissociation curve............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
- Physiological significance of the 02-Hb dissociation curve... . . . . . . 67
- Myoglobin .................................................................. 68
-Factors that shift the 0 2-Hb dissociation curve to the right ...... .. 69
-Role of2-3 DPG in 02-Hb dissociation ............ ... ............... ... 70
-Factors that shift the 0 2-Hb dissociation curve to the left ............ 71
Chapter 7: COz transport (carriage) by the blood_._.. .... - ··--· 72
- C02 in the arterial blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
-The tidal C02... .. . . . . . . . . . . . . . . . . .. . .. . . .. .. . .. . . .. .. . . . . . .. . . . . . . . . . . . . 72
-Tidal C02 excretion in the lungs.......... ...................... ....... 75
- The chloride shift.. .... ................................. ... .............. 76
- Gas exchange in the tissues and lungs... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
- The C02 dissociation curves................................... . .... .. . 77
Chapter 8 : JJypo.x.ia, acclimatiza1ion ami c:yanosis ............... 79
- Hypoxic hypoxia............... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
- Anaemic hypoxia ........... ..... .......... ......... ....................... 79
- Carbon monoxide (CO) pOisoning. .................... ...... ......... 80
- Stagnant (ischaemic) hypoxia... ... ........................ .... ........ 80
-Histotoxic hypoxja ............ ..... ....... ......... .............. ..... .. .. . 81
...{ya,nide poisoning...................... ....................... . . . . . . . . . .. 81
-Acclimatization ..... . ............................... .. ... .. ............ .. ... 82
-Cyanosis ..... ...... ....... ....... ............ ...... ..... ..... ..... .......... 84
- Oxygen ther~JJY ... ........ ... . ............... ... ........... . ...... .. ....... 86
Chapter 9 : 1Jy.'iiology of deep sea dh•inK .. . • .. . .. . .. . . . . . . . . . . . ... 88
- Nitrogen narcosis ... ... .......... ............ .............................. 88
-The high pressure nervous syndrome ... ...... ...... ... ............. .. 89
- Decompression sickness ..... . ... ...... .................. ..... . .... .. ... .. 89
- Air embolism and explosive decompression ............... ....... ..... 90
CHAPTER 1
EPIGI.Ol"TIS
CI.OTTIS
PVLMONAIIY
ARTERI[S
PUUIONAIIY - ....,.-.;~:,..;
VEIHS
still smaller tubes called the bronchioles. This system simulates a branching
tree, so it is frequently called the bronchial tree (figure 2 left). The bron-
chial diameter is generally more than 1.5 mm, while that of the bronchioles
is less than 1.5 mm.
Functi onally, the bronchial tree is divided into 3 zones (figure 2 right) :
1. Conduction :;one : This extends from the trachea down to the ter-
minal bronchioles (the 16th generation of the bronchial tree). lt
receives bleod supply frem -the -bronchial «rterie.s (which are
branches from the aorta) and since no gas exchange occurs in this
zone, it is called the anatomic dead space (see later).
3. Re.\rirarorp :.one : This includes the alveolar ducts, atria and alveol-
ar sacs, and it receives blood supply from the pulmonary arteries. It
is the main site of gas exchange, which occurs in the alveoli. The
latter are located mainly in the alveolar sacs, and few are also pre-
sent in the alveolar ducts and respiratory bronchioles (see above).
4
Chapter I Tlze respiratory svstem
The trachea and large bronchi are kept open by in complete carli-
lageuous rings in their walls. There are also cartilagcnous plates in the
wal b o f the smaller bronchi, but they become progress ively less in the later
generations of bronchi, and are almost absent in the bronchioles.
The walls of the tracheobronchial tree also contain smooth musc le
fibre ~ (wh ich arc few in the trachea and large bronchi but abu ndant in the
bronchioles, specially the terminal bronchioles). These muscle fibres relax by
sympathetic stimttlatioll (resulti ng in bronchodilatation) and contract by
para.oiympatltetic stimulation (resulting in bronchoconstriction).
r--:- '
TRACHEA ~
1-- -1~
g r 2
!
7
BR _ . 1
('\__!L
j ,.,- " 7~
u
I,.,~ ' l ~ i
§ I ~~ 11, ,
~\Ug""jRBL ~ \-- -
- -18'
I.-: . . I '-.v'"': C 0
, - -19
20
~ AD _ , ' - '<. • ;> 1
~1~~AS i.Ft~
F igure 2 : X-ray photograph of the bronchial tree (left), and its anatomical and functional
divisi ms (right). Z =Generation number. BR = Bronchi. BL= Bronchioles. TBL= Terminal
bronc1iolcs. RBL= Respiratory bronchioles. A D= Alveolar ducts. AS =Alveolar sacs.
The inner walls of the tracheobronchial tree are lined by mucous memb-
ranes consisting of ciliated columnar epithelial cells (about 200 ci li a on each
cell). In the trachea and large bronchi , these membranes contnjn goblet cells as
well ts submucosal mucous & serous glands, the secretion of which is
stimulated by parasympathetic stimu lation (but these glands arc almost absent in
the bronchiolar walls). Cilia are present till the beginning of the respiratory
bronchioles , and they beat upwards at a rate of I 000- 1200 times/minute (which
drives mucus and foreign particles towards the pharynx at a ve locity of I 0- 16
mm/minutc to be eliminated). This mechanism is called ciliary escalator, and if
it is Jefective e.g. congenitally (= Kartagener's syndrome), it leads to chronic
sinu sitis and recurrent lung in fection
5
Chapter I The respiratory system
I THE LUNGS I
The lungs contain the bronchial trees, and their main bulk is made up
by the respiratory zones Q( these trees in addjtion to a very rich blood
supply from both the pulmonwy arteries and the bronchial arteries (sec
above). They are formed of lobes (3 in the right lung and 2 in the left lung),
each of which consists of a large number of lobules.
Normally, there is a thin layer of fluid between the lungs and chest
wall in the pleural cavity (page 6) which facilitates free sliding of the lungs
on the chest wall and also keeps them in close contact with each other (in
the same way that 2 moist pieces of g lass slide on each other but resist
separation).
(A) Role of the alveoli : Foreign particles that reach the alveoli (e.g. dust
and the rnicroor_ganisms less than 2 microns in diameter) are attacked and
phagocytosed by the pulmonary alveolar macrophage.., (see above).
In addition of being a part of the air passage, the larynx is also con-
cerned with vocalization or phonation (sound production) . This is produced
as a result of vihrations C?! the vocal cord'i while air is passing out of the
lungs by a voluntary expiratory effort, and the _pitch of the sound is determi-
ned by the frequency of vibration of these cords. Such frequency in turn de-
pends on the tightness of the vocal cords as well as their shape and mass of
edges. All these changes in the vocal cords are produced by activity of the
laryngeal muscles, which are voluntary muscles supplied by the vagi nerves.
AS "HMA
I EMPHYSEMA I
This is a degenerative lung disease characterized by loss of the lung's
elasticity and breakdown of the alveolar walls (so the alveoli are replaced by
large air sacs). Its commonest cause is lteal'y cigareue smoking. The smoke
increases the numher of the PAMs (= pulmonary alveolar macrophages),
which release a chemical substance that al/racts the leukocytes to the lungs,
and these secrete (n) The elmita.\·e enzyme, which attacks the elastic tissue in
the lungs (b) 02 rudicles, which block the action of a protein in the plasma
called alpha 1 antillypsinthalnormally inactimtes the elastase enzyme.
In about 2 % of cases. there is congenital tleficienc.J' of antitrypsin 1.
and smoking in such cases leads to a severe kind of emphysema early in life.
liFECTS OF SMOKING
CHAPTER2
volume (see below) The various lung volumes and their average normal
va lu e~ in young adult mules include the following (figure 4) :
This is the volume of air that moves into the respiratory passages (i.e.
inspired or expired) in a single breath cycle during eupnea (= normal resting
quiet breathing). 17te average TV is 500 mi.
~----~---.-----.~~---- -
Max1mal
msplfalory
level
: IAV ::
IC
vc
TLC
FAG
Max•mal
RV oxp~ratory
lovel
FW.u rc 4 : A normal spirogrnm showing the various lung volumes & capacities.
13
Chapter 2 Tlte lung l•n/um es and capacities
This is the volume of air that rem ains in rite lungs after rite end of a
m aximal expiration . Its average value is 1200 ml, and it can be expelled out
of the lu ngs only qfter !heir collapse (e.g. after opening of the chest) .
The minimal
I
air (or volume) and its clinical importance
After opening of the chest, however, about 150 ml of air still remain
in the lungs. This is called minim al air or ''olume, and it is used m edicoleg-
ally in detecting whether a newly hom dead baby had died before or after
delh•ety. This is known by placing a piece of the baby' s lung in water. lf it
tloats, it indicates presence of the minimal air (i.e. the baby was born alive
and breathed then died). On the other hand. if it sinks, it indicates absence of
the minimal air (i.e. the baby was born dead and had never breathed).
This is the volume of air that rem ains in tfte lungs after the end of a
n ormal resting expiration . lt equals the ERV + R V = about 2200 m i.
14
This is the volume of air that can be expelled out by a maximal expira-
tion ufter a maximal inspiration . It equals the TV+ JRV + ERV = about
4500 mi. However, it normally varies with the size of the body. Accordingly,
its mrasured value must be predicted relative to the body surface area. Nor-
mally. it averages 2500 ml and 2000 ml per square meter of body surface
area irr young adult males and females respectively .
This is the volume of air that the lungs contain after a ma..·dmal
inspiration. lt includes all lung volumes (TV + 1RV + ERV + R V) or, in
other .vords, it equals the VC + RV = about 5700 mi.
Drum
Floatlni Drum
r.==~==;i/
.Vormally, the RV i.v le.vs than 30 % of the TLC. Such ratio is exceeded
in d i s~ases that cause inefficient expiration, part icul arly asthma & emphy-
senw and ratios more than 35 % indicate that the condition is serious .
The FRC maintains an adequate gas exchange in the lungs in the inter-
vals t-etween breaths, and its large volume (about 5 times the TV) prevents
acute changes in the 0 2 and C0 2 concentrations in the blood. lt can also be
measured by using the dilution principle (see above). but in this case th e
su bjec:t starts breathing in the spirometer after a normal expiration .
[ )IFFERENCES
I
BETWEEN ALVEOLAR AND EXPIRED AIR
The alveolar ai r is that air that undergoes gas exchange with blood in
the pulmonary capillaries. Its volume is about 2000 ml after a quiet expira-
tion. t continuously loses 0 2 and gains C02, so its 0 2 content is less and its
C0 2 ( ontent is more than the amounts of these gases in both the inspired and
thee>pired air (see the table below).
During inspiration, the air conducting part of the respiratory passages
(whic11 is called the anatomical dead space) contains atmospheric air. flow-
ever during the next expiration, this air is exhaled first and is fo llowed by
alveolar air (which .fills the anatomical dead ~pace cifter expiration). There-
17
Chapter 2 The lung volumes and capacities
fore, the expired air is a mixture of alveolar air and atmospheric air from
the anatomical dead !<.pace.
The following table shows the composition of the inspired, expired and
alveolar air, all fully saturated with water vapour (PP = partial pressure in mmHg).
I '<ttrQ:J~n mete~1
:r
'lO
'
zol
o-~ ,___~-----+--
.-J nsptrat•on . , _ hptratton-
*"' Pure alveolar air is difficult to obt~ and the last few ml of the
expired air are usually used instead. However, since the alveolar air and
arterial blood are normally in equilibrium , the Pc02 in both is equal, and
accordingly, in Bohr' s equation, the Pcm in the arterial blood (which is easy
to measure) can be used instead of the Pc02 in the alveolar air.
ASSESS~ENTOF~~MONARY~~NCT~
(THE PULMONARY FUNCTION TESTS)
LHapre~Tf~2~----------------------~T.~h~e~l~u~n~c~•~·f~JI~u~m~e~s~a~"~d~c=a~p~a=c~·u~ie=~
'I hts is the totalmlume c?f wr thai is mvnred per IIIII lUte It is calculated
b\ m tltiplying the (T\ ') x breJthing rate per minute Since normall) the
formt.. ~ is about 500 mi. and the latter about 12 per minute. then the nom1al
total 1'\' (or RM\') = 50() xI 2 = 6()()0 ml (6 litre'i) p er minute
"'his is the 1'0/ume of air thai actual(r wmilates the ah·eoli per minute
Since about ISO ml of the inspired TV nom1ally remain in the anatomical
dead ,pace, then during rest o11~r ahout 350 ml (~(the Tl' reach the ah·eo!t
eac:h .wealh. and the resting al\'eolar ventilation 3SO x 12 4200 ml (4. 2
litre.\) per minute.
I UTRE{ : IF'E:VI
f:
I I
~v, I 1
:._.: ~
!SEC 1 SE C I SEC
VC 4 ·0L VC 2 •0L VC 2 • 5L
re:v,J ·2L n:v1 t·7L FE:V10 · 75L
(o80 '/, V. C) <• 85 '/, V.C) (.30'/. V.C. I
I DYHPNEA I
Dyspnea means difficulty or shortness of breathing of which the person is
aware. It develops when the dyspneic index decrease.tt below about 70 %
(see above). This occurs due to either a decrease in the MBC or an increase
in the MRV (e.g in cases of acidosis and hyperthyroidism). Dyspnea also
occurs in the following conditions :
1. If the work of breathing increases due to any cause.
2. f( the mechanical efficiency decreases (e.g. in obese persons).
3. In certain psychological conditions.
23
Chapter 2 The lung volumes and capacities
I ORTHOPNEA I
I
\
24
CHAPTER3
Ondme's curse
This is an old legend that tells about a man who had lost lti.'i automatic
control of respimtion. In such case, respiration can occur only by voluntary
control, and to maintain life, he should stay awake to remember to breathe
volumarily, which is evidently fatal due to either exhaustion or the resulting
apnea if he fell asleep. Such condition can also occur if the respiratory cen-
tres a1e damaged e.g. in cases of bulbar poliomyelitis.
--------~A~~ AAfl
D
Vagt cu t
• Pona
I
I
& ·~ - -
Pne w:.otax ic
• · ce:-~;.rl'!
- Apr.cue~ 1.c
ce:~tre
I
I
I
I
centre
I
I
I
•
rcopna to ry
troct
'
phrenio
!lene
outwards and the lungs are deflated. Such deflation occurs slowly because
the inspiratory muscles are partially contracted in the early expiration
(which exerts a braking action on the lung recoil forces).
On the other hand, the muscles of expiration contract onlv during for-
ced expiration (e.g. during muscular exercise) and in cases of increased air-
way resistance (e.g . asthma) and diminished elasticity of the lungs (e.g. em-
physema). The expiratory muscles include mainly the following :
l. The anterior abdominal wall muscles : The contraction of these muscles
increases the intra-abdominal pressure, which causes bulging of the diaphra-
gm upwards into the chest cavity, thus helping outward expulsion of the air.
2. The internal intercostal muscles : These muscles extend obliquely down-
ward~ b ~' k' w ~ f cibetween the ribs, so their contraction causes depress-
ion of the ribs, whict1 reduces the ~hest volume and helps expiration.
- lmpr· I Expi· I
1 ratron - - ration - ,
2
I I
Intrapu tmonary
v\
~
•I
pressure
0
/ Pressure
/
/ ''
/
/
/
''
'
/ '
/
/
"' lntraJileural
~ pressure r
-I
-2
·3
tmm Hgl
/
/
/
/
\ I -4
/
/
/
/
/
/
'1\ I I -5
/ -6
/
0.6
Volume ol
breath / ""- Volume
0.4 (litersl
I \
0.2
/ I" 0
0
~ .,.he inflation receptors are not adequately excited till the tidal volume
exceeds I litre. Therefore, tlte Hering Breuer reflexes normally play a
little role during eupnea in adults. However. they become imponant during
.<deep & anaesthesia (in which they provide a prutectil•e mechanism again.~!
excefisive iriflation and deflation of lhe lungs). Also, the inhibitory vagal dis-
charge du ring inspiration shares in producing rhythmic breathing (page 26).
~ It was reported that innell'ly-bom ilifants, lung inflation excites the apn-
eustiC centre leading to a prolonged inspiration and more lung inflation.Such
resp mse is called the paradoxical reflex. However, its presence is doubtful.
31
1. "he elastic property of the lungs : T his is due to the elastic elem ents
in the lungs~ ~he elastin & collagen fibrest t/a) a..r~d the surface tension
of the fluid layer that lines the alveoli (. 2/ 3 ). It tends to decrease
the lung's volume, thus pulling the visceral pleura inwards.
2. ]he elastic property of the chest wall This tends to expand the
t'loracic cage, thus pulling the parietal pleura outwards (page 35).
The IPP varies with the body positi on as well as in the different parts
of tl e pleural cavity due to the effect of gravity (see below). The following
are the average normal values in the standing position .
I ALVEOLAR STABILITY I
This term means stability of the size of d(fferent ah•eoli It is produced
by::! factors : t!Je surfactant and th e property of alveolar interdependence.
ALVEOLAR INTERDEPENDENCE
This is a property in the alveoli by which they support eac:lt other. so
that a change in the volume of a certain group is opposed by the surrounding
groups e.g. the tendency of a group of alveoli to collapse is antagonized by
development of strong expanding forces in the surrounding groups (figure
12). Such property obviously helps in maintenance of alveolar stability
The lungs and chest wall are elastic structures Each has a resting posi-
ti on at which it is neither stretched nor compressed, and tltey always tend to
acquire this po.~ition. The volume at the resting position is called the relax-
ation volume, and in normal adult persons, that volume of the lungs is about
one litre while that of the thoracic cavity is about 3. 5 litres.
In the midthoracic position, each of the volume of the lungs as well as
that of the thoracic cavity equals the FRC (functional residual capacity) i c
about 2.2 1itres. This is call ed the relaxation l'Oiume of the respiratory sys-
tem and at such volume, the '""K-'" are stretched ll'hile the thuraclc cal'i~)' is
compressed Accordingly. the lungs tend to recoil while the chest wall tends
10 expand. creating the negatil•ity of the /PP (page 32). In other words, the
tendency of the lu11gs to recoil is balanced hy a tendency of the chest wall to
recoil by m1 equal degree btll mthe opposi1e direction (i.e. outward~)
00
1t :&1~,------l
OF OI!ST 'HlU.
60
VITAL
CAPACITY
(%) •o ntsTIHO
- - - n(SPIAATOIIY--~·
L(Y(L
RESIOUAL
VOLUME ,
I
-30 -l<> 0
INTRAPULMONARY PRESSURE
~teraction between the recoil forces of the lungs & chest wall I
This is shown in the pulmmwry relaxation pressure cun•es (figure 13).
The relaxation pressure at a certain volume is the imrapulmonat)' preS.\'111'1!
reel rdeJ at that volume while the respiratoty muscles are re/a'~:ed. The re-
laxa tion pressures of either the lungs or the chest wall results from the recoil
force of each, while that <?f the whole re~pmlloty .\ y.\lem is the re.Yultant of
the ~'ec:oll fon·es of both the lungs and che~t wall together (the midtlle solid
cun·e ;, figure 13). The latter is constructed as follows : The subject inhales
or exhales a certain volume of air from a spirometer, then the connection to
the apparatus is closed and the subject relaxes his respiratory muscles as
completely as possible while the intrapulmonary pressure is recorded. This
prO< edure is repeated with other volumes, then such volumes are plotted
against the corresponding intrapu lmonary pressures.
The relaxation pressure curves show the following :
J. At the midthora cic position (when the lungs contain the FRC), the rela-
"< Hion pressure of the lungs alone is about + 5 H20 (as they tend to recoil)
~ hile that of the chest wall alone is about - 5 H20 (as it tends to expand)
a 1d since both forces are equal but opposite, they cancel each other and
the relaxation pressure of the whole respiratory system becom es zero.
2. At volumes exceeding the FRC , the relaxation pressure of the lungs
becomes more +ve [because their recoil fo rce increases] while that of
tl e chest wall becomes less -ve [because its recoil force decreases as it
a )preaches its resting \'Oiume (about 3.5 litres)] and, consequently, the
rc•laxation pressure of the wh ole respiratory system becomes positive.
3. At a volume of about 3.5 lit res (70% of the vital capacity), the relaxa-
tion pressure of the lungs becomes more and more +ve [because their
rtcoil force further increases] while that of the chest \\'all becomes zero
[because its recoil force disappears as it reaches its resting volume] and,
consequently. th e relaxation pressure of tlte whole respiratory system
hi!cmtu!s more positil•e
4. At volumes exceeding 3.5 litres, both the lungs and the chest wall tend to
recoil inwards, thus they operate additil'ely producing a further increase
i11 th e relaxation pressure of the whole respiratory system (which reach-
e . a ma.ximum of25-30 em I hO at 100 % vital capacity)
5. At volumes less than the FRC, the rela.xation pressure of the lungs be-
comes less +ve [because their recoil force decreases) while that of the
chest wall becomes more -ve [because its tendency to expand increases]
and, consequently, the relax ation pressure of the whole respiratory .s:rs-
tem becomes negatil•e ( about -20 cmH 20 at the residual volume) ..
37
O wpter 3 !v/echanis m (mechanics) o[hreatlting
"'
I' II ' S S U R F:
~ olid curve in figure 13), and is usually measured at the .\leepest part of
tlte cun•e, which covers most normal resting breathing (figure 14).
C
r -------------- B
~l 1
I
I
I
I
I
I
Tuldl
volume
I mil
0 ~----~~--r----,
0 -2 A • - 4 -6
lnlrapltu r~l pressure
lmm lt]l
2.. >ynamic complianrr : This is the compliance or the lungs during the
I reathing cycle, and is determined from the dynamic: pres.mre l'olume
curve of the lungs (figure 15), which is constructed as follows : The
subject inhaJes air from a spirometer ill steps till the maximum (50- I 00
r tl each time) and the IPP is recorded at the end of each step (through an
i lira-esophageal balloon connected to a saline manometer) lie then ex-
1ales in steps unt il the resting lung volume is resumed. and the IPP is also
r ~corded at the end of each step The changes in the lung' olume are then
rlolled against changes in the IPP 1l1e normal c:url'e \hmu lhe {ol/ou'll1g
I . I is in the form of a hy.\lere.\ is loop i.e. the changes in the lung volume
duri ng inflation and deflation are different (which is called hysteresis) It
is due to \'iscous properties (frictional resistance) in the lungs (see below).
2. I he lung compliance i~ gretller when m easured during deflation
3. I he dashed line (A YJJ) repre.~ents the average lung compliance.
cuE E 50 I
::.E
-::>
oe
I
> ;:; I
"'
E
I
~
0
0 10 20 30 40
Pressure lcm H,Ol
conditions that cause increase of the lung compliance, e.g. emph ysema
am/old age.
~ The thoracic compliance is decreasetl in cases o( (I) Deformities
of the vertebral column e.g kyphosis(= antero-posterior bending) and scol-
iosi!- ( lateral bending) (2) Arthritis of the joints of the thoracic cage or the
vert~bral column (3) Skeletal muscle diseases (4) Obesity.
6
N orm ... l
~
~
..
E
5
·~ 4
...
~
...."" J F1brO\It.
0 ----~------~-----
10 20
l------~•10
:lO
0
runuou1mon~ry prtswro (em H 1 01
1. Elastic ~compli ance) worl<: This is about 65% o{llte total work, and is
u~cd for stretching the clastic tissues of the lungs and chest wall (i.e for
0\ creaming tbeir elastic recoil forces).
2. Nun-elastic (resistive) work : This is about 35 t~ o(the total work.and is
u~ed for resisting the frictional resistance to air mO\ ement in the lungs It
in ·ludcs the following I) pes of work :
a- Aim•av resistance ll'orA (28 %) : 1 his is the work used to overcome
1he resistance to air flow through the rcspi1 a tory passages.
h- Tissue re.5istan ce work (7 %) : This is I he work used to overcome
the viscous resistance in the lungs.
41
tt 0•
The work of breathing can be determi ned from one n(tlt e {ollmving cun•es :
{a)
(,:/<·)
\{}' \
~~~
\., -
Figure 19: A slinky spring (a) freely suspended. (b) pulled down
tion because it is situated at the steep part of the pres.m re wJiume cun·e)
Conversely. the lPP is high in the apex (-I 0 em! hO) ), so this region has a
large resting volume (thus it expands little during inspiration).
·~ em 1<1 0
lntra p e ur ill
fll" t••, t.;urt
(HV)
( t ))
-
10 :>0 30
Figure 20 : Normal lung conditions during staml111g (a) At rest when they
contain the FRC. (b) Afier maximal expiration when they contain the RV
Due to gral'ity, the pulmonaJy bloodjloll' at the lung ap1ces during stand-
ing is much less than that at their bases. It is decreased in the lung apices to
the extent that raises the V/P ratio to 3.3. On the other hand, the increase in
blood flow at the lung bases reduces the V/P ratio there to 0.63 (page 21 ).
44
Chapter 3 Meclzani."im (mechanics) o[breathing
I PNE JMOTHORAX I
This is entry of air inside the pleural cavity. This may occur due to
an external cause (e.g. injury of the thoracic wall) or an internal cause (e.g.
rupture of the alveoli into the pleural sac). The IPP increases, leading to
collapse of th e !twg on the affected side and shift of the mediastinum to
the normal side. The condition is fatal if bilateral, and it is several t}'pes .
1. Cl lsed pneumothorax
This is the mildest type, in which the hole in the pleural sac seals off
and the air that entered the pleural cavity is gradually absorbed (so the colla-
psed lung will slowly re-expand).
In this type, there is a flap of tissue over the hole in the pleural sac,
which acts as a flutter valve that permits air to enter during inspiration but
preve1 ts its escape during expiration, so the JPP rises above atmospheric.
The hypoxia is more severe, and respiration is excessively stimulated, which
further increases the IPP (up to + 20 or + 30 mmHg). Kinking of the great
veins causes distension of the peripheral veins and cyanosis. Shock may
finally occur, which may lead to death.
CHAPTER4
CSF
....
-7co, ·: ·: .:.=~ : .~:.:." ·\
, . , ., . . ·.-..: ; ' ..._, ~:
. .·.·:. ·.·. .
. '
·rhe only blood gas that excites the central cltemoreceptors is C02, so
they ate stimulated only in cases o flt)percapnia. The action of C02 is due
to the H+ it produces in the brain fluids, w hich occurs as follows : The C02
in the trteriaJ blood easilv crosses the blood brain harrier (figure 21) and
reaches the brajn fluid s, w here it combines with H20 by activity o f the carb-
o/lie anhydrase en zyme, forming H2C03 (= carbonic acid). This acid then
dissoc atcs into HC03- and Jl ' (which stimuJates the cent raJ chemoreceptors)
~ These receptors are insen sitive to hypoxia and cannot also detect
changt·s in blood pH (because Jr cannot cross the blood brain barrier).
2. Pf ripheraJ chemoreceptors I
T tese receptors arc present mainly in the carotid and aortic bodies. The
formc1 are located bilaterally at the bifurcation of the common carotid
arteriei whlle the latter are located close to the aortic arch (fi!:,rure 22). The
signals generated at them are conveyed to the respiratory centre by the
carotid sinus (or Hering) nerve and the aortic nen•e. These nerves are
branches of the 9"' and IOth cranial nerves respectively, and are commonly
called .he buffer nen•e.'i (refer to circulation).
Glossopharynqeal
nerve )
Carotid body
Lelt
subclavian
artery
lnnommat,
arttry
curves show the same relationship when the alveolar P02 is simultaneously
decreased . In the latter, it is clear that the slope of the C0 2 response curves
increases (i.e. more ventilatio n occurs at a certain Pc02) and that the degree
of slope is directly proportionate to the magnitude of decrease in P02.
100
/~
.
li
(B) The limbic system : This influences breathing during emotions (tachy-
pnea occurs in some emotions while apnea occurs in some other emotions).
(B) From the ia·ritant a·eceptors : These are rapidly-adapting,. and excita-
tion o f those in the nose produces sneezing (or apnea if the irritant is strong
e.g. ammonia), while excitation of those in the trachea or bronchi produces
coughing and bronchoconstriction. On the other hand, excitation of those in
the larynx produces coughing and laryngeal spasm, while excitation of
those in the lungs produces hypetpnea.
(C) from the juxtacapillary {J) rereptors : These are located close to the
pulmonary vessels and they are stimulated by ( 1) Hyperinflation of the lungs
(B) From the swallowing receptor area : This area is located at the entra--
nce of the pharynx. Its stimulation by food during deglutition initiates inhib-
itory signals to the respiratory centre leading to apnea for 2-3 seconds. This
is a protective reflex that prevents food entrance into the resp. passages. A
similar effect occurs during vomiting when the vomitus reaches the pharynx.
HICCUP
YAWNING
This is a respiratory act characterised by deep itl.'lpiratimr and stretch-
ing of the chest wall. It is usually associated with a desire to sleep and is an
..infectious act of unclear physiological significance. However, like sighing
page 34), it h elps opening of tlte hypoventilated al11eoli and may be also
the ''( 11ow; return to the heart.
"
.:r FUN:TJONS OF THE PULMONARY VAGJ NERVES
(A) The afferent nerves : These transmit (a) signals of many reflexes
c g. the Hering-Breuer and cough reflexes (b) signals from the chemo-
receptor.<; in the aortic bodies, heart and lungs (c) signals from the
baroreceptors in the aortic arch. atria and ventricles
(B) The efferent nerves : These produce (a) broncboconstriction (b)
V.D. of the pulmonary vessels (c) mucus secretion from the respiratory
.. mucous membranes (refer to the autonomic nervous system) .
t. Voluntary apnea (by signals discharged from the cortical motor areas).
2. Deglutition or swallowing apnea (page 5 1).
3. Stimulation of the baroreceptors e.g. adrenaline apnea (page 50).
Figure 26 : Changes in the arterial P02 and Pc02 during periodic breathing.
respi1 ation resulting in hyperpnea. This increases the arterial Pm and decr-
eases the Peen, which result in apnea once again, and the cycle is repeated .
ARTIFICIAL RESPIRATION
Supine
Supmt ··~Ill
prrssurt ll·
mouth
1. Shafer' s method : The patient is placed in the prmre position . and the
rescuer (saver) puts his hands on his lower ribs and presses the sides oft he
chest for 2 seconds then releases the pressure for 2 seconds. This procedure
is repeated 12 times per minute, but however, it is of little use.
58
Clra1'ter 4 Regulation (control) o(breathing
3. Howard's method : The patient is placed in the .\·upine position, and the
rescu<:r applies intem1ittent pressure on hi s chest (figure 27 B I). However,
this method is also of little use.
CHAPTERS
( ias and air volumes vary with both the temperature and pressure as well
as with the presence or absence of water vapour. Therefore, for comparison
of various volumes, the effects of these factors should be eliminated. This
is ac ieved by prediction (correction) of the measured volume to one ofthe
following standard conditions :
I . S TPD [standard temperature and pressure, dry] i.e. 0°C, 760 mmHg, dry.
2. BTPS [body temperature and pressure, saturated with water vapour].
3. A I PS [ambient temperature and pressure, saturated with water vapour].
GA 5 DISSOLUTION IN FLUIDS
Thi ~ law correlates the various factors that determine the volume of a gas
that difiuses across a given membrane per unit time as follows (jig11re 28) :
61
::7
C0 D"' So l
2
..jM VI.
This process occurs as follows : The average P02 In the venous blood
flowing to the lungs (through the pulmonary arteries) is 40 mmHg, while it
is aoout 100 mmHg in the alveolar air. Therefore, 02 diffuses rrom the
alveolar air to the venous blood. On the other hand, the average Pc02 In the
venous blood is 46 mmHg, while it is about 40 mmHg in the alveolar air.
Therefore, C02 diffuses from the venous blood to the alveolar air. After
eqwlibration, the (P) of these gases in the pulmonary veins (which carry
arterial blood) become nearly equal to their corresponding values in the
alveolar air (the P02 about 97 mmHg and the Pc02 about ../0 mmHg).
The diffusion capacity of the lung for a certain gas is " the volume
of this gas that diffuses acros.fii the alveolo-capillary membrane in ml I
minute I mmHg ofpressure gradient".
I Normal values I
The normal lung diffusion capacity for 0 2 during rest is 20-25 ml I
minute I mmHg, while that for C02 is about 20 times 6Tfeater (.f00-500 ml
minute mmHg) because of the much greater sol ubility of the latter (see
above). During exercise, these values increase 2-3 times due to a marked
increase in the surface area of the a/veolo-capillary membrane, which
occurs as a result ofthe following :
1. An increase in the alveolar surface area (by opening the inactive alveoli).
2. An increase in the number of active pulmonary capillaries.
3. Dilatation of the pulmonary capillaries.
I Measurement I
It is difficult to measure the lung diffusion capacity for either 02 or
C02 . However, measurement of the diffusion capacity for carbon mono-
x ide (CO) is much easier. The normal value of the latter is nearly equal to
that of 0 2 (about 25 ml I minute I mmHg), and its determination is used as
an index for the efficiency of gas diffusion in the lungs.
64
CHAPTER6
According to the level of P02, oxygen flows downhill from the alveolar
air to the blood then into the tissues (figure 29).0xygen supply to the tissues
is the fimction of the respiratory and cardiovasculr lystems, and the amount
deli ;ered depends on (a) The amount of02 that enters the lungs (b) The etT-
iciellcy of gas exchange in the lungs (c)The capacity of the blood to carry 02
(d) The rate of blood flow to the tissues.
ISO
£' 120
e
§
~ 90
~
i 60
...
~ 30
0.
0 ~~----~----~--~
Air l ungs 81000
The following table shows the normal (P), % Hb saturation with 02 and
volumes of0 2 & C02 in ml I dL (100 ml) in an erial & venous blood a t rest.
Notice that norma lly at rest, the arterial blood contains about 19.8 ml
0 2 I dL while the venous blood contains only 15.2 ml 0 2 I elL, which indica-
tes that each 100 ml of a rterial blood supplies the tissues with 4.6 ml 0 2 .
OXYGEN CONTENT I
This is the volume of 0 2 (in ml) present in chemical combin ation (i.e
bound to Hb) in I00 ml blood.
OXYGEN CAPACITY I
This is the maximal volume of 02 (in mJ) that can be carried in che-
mical combination by I00 ml blood (i.e. when Hb is completely saturated
with oxygen).
I OXYGEN % SATURATION I
This is the % saturation of Hb with 0 2, and it is calculated as follows
0 2 % saturation = oxygen content x 100
oxygen capacity
66
Chap~~~r~6~----------------~0~xv~ce
~n~u~a~n~sp~o~rl~~~·a~r~n~·a~g~e)~bv~a~,e~b~l~o~od
** fhe average normal values for the Pm and 0 2 content in the arterial and
venous blood during rest are shown in the abo':'e. table (page 65).
~ Since there is normally about 15 gm Hb I nil blood and each gm combi-
nes with about 1.34 ml 0 2 , then the normal 06 capacity of blood =
15 x 1.34 = 20 ml 02 I tOO ml blood (approximately)
100
~ 80
....
~
ex: 60
:::>
~
Vi
A NORMAL HUMAN BLOOD
I-
z B MYOGLOBIN
w
u
ex:
20
w
Q.
0 20 40 60 80 100 120
OXYGEN PRESSURE . mm . Hg
F igure 30 : The 02 dissociation curve for blood Hb (A) and myoglobin (B).
[MYJGLOBIN I
This is a red oxygen-carrying pigment found in skeletal muscles,
spec ally those specialized for prolonged contraction (i .e. the slow muscles
that are rich in red fibres). Its molecular weight is V.. that of Hb ( 16700), and
its molecule contains only one haem unit that contains one f e"ous atom
and can bind only one oxygen molecule (Oz) .
The myoglobin 02 di ssociation curve lies to the left of the Hb 0 2 disso-
ciation curve and is in the form of rectangular hyperbola (figure 30B). This
indicates that myog lobin retains (or stores) 0 2 when the 0 2 pressure is high
and ~eJeases it only at low 02 pressures. It perfo rms a complem entary fun c-
tion to blood Hb because the steep part of its curve comes after that of the
Hb curve (thus at low 0 2 pressures, myoglobin can release its 0 2 content to
the t ssues at a time the release of 0 2 from the blood Hb becomes minimal).
69
Chapter 6 Oxvgen transport {carriage) bv the blood
I The Pso I
This is the 02 pressure at which Hb is 50 % sarurated with 02. 1t is
an index for shifts of the OrHh dissociation curve. The normal Pso at r~·t is
about 26 mmHg. It increases when the curve is shifted to the right (i .e.
when the Hb-02 affinity is decreased) while it is decreased when the curve
is shifted to the left (i.e. when the Hb-02 affinity is increased).
90
10
,
pO, """Hg
Figure 31 : Effects of changes in the arterial Pc02 on the 0 2-Hb diss. curve.
0 20 40 60 80 0
Figure 32 : Effects of changes in the temperature (left) and blood pH (right)
on the 0 2-Hb dissociation curve.
CHAPTER 7
Depending on the Pc02 level, C01jlows dmvnhill from the tissues to the
blood, then to the lung alveoli, where it is eliminated outwards (figure 29).
I TH E TIDAL C0 2 I
This is the volume of C02 that is added to each I00 ml of arterial blood
duri11g its flow through the tissues. It is normally about 3.7 ml during rest,
and 1t increases the C02 content in the venous blood to 52. 7 ml I dL and the
Pcm to about 46 mmHg (see table in page 65). It is transported in the same
73
Gnapter 7 co~ transport (carriage) bv the blood
proportions as the C02 already present in the arterial blood (i.e. mostly in
the chemical form) so as to keep the ratio HC03· I H2C03 unchanged and
the blood pH constant at 7.4. Accordingly, it is transported as follows :
--\o....o\+-- H,O
----~-H COi'
Na'
Figure 33 : Buffering of C02 in the red blood cells. Notice the Cr shift.
74
Chapter 7 col transport (carriage) bv the blood
FatH of HC03 in the plasma and red blood cells
Both oxyHb (Hb02) and reduced Hb (Hb) are weak acids because their
i.welectric point.-. are less than the pH inside tlze red blood cells, which is
7. 3 (refer to blood). Accordingly, they combine with K+ (the main base pre-
sent inside the red cells), forming KHb(h and KHb. However, Hb02 is
mm e acidic, so it combines with more K+ . Therefore, in the tissues when
I-lb02 delivers 0 2 and becomes reduced Hb, some K~ is released as follows :
Kl I b02 (K-oxyhemoglobinate)~ KBb (K-hemoglobinate)+02 +some K+
Some K is also liberated as a result o[lf buffering (.~·ee next) .
Th~ released I-f" after dissociation ofH2C03 is buffered in the plasma bv the
pkwna proteins and in the red blood cells by Hh.Reduced Hb is a stronger
W acceptor than oxyflh, and when it buffers H •, K is liberated as follows
H+ + KHb ~ H.Hb (hemoglobinic acid)+ IC
H.Hh is a verv weak acid that minimall>' diswrbs rhe pH (see below).
Rol ~ of the plasma and red blood cells in tidal CO~ carriage
1. Role of the plasma: This carries about 10 % of the tit1al C02 ( 5 % disso-
lved and 5% as HC03 · , and a very small amount as carbamino compounds).
2. Role of the red blood cells :These carry about 90% of the tidal C02(5%
dissolved, 25% as carbHb and 60% as HCOJ}
1. T1e dissolved amount of C02 increases, so the Pco2 in the venous blood
increases to 46 mmHg
2. The carbamino compounds are increased (specially carbHb).
75
Chapter 7 col transport {carriage) bv the blood
3. HC03- increases in both the red blood cells and the plasma.
4. c r increases in the red blood cells and decreases in the plasma.
5. The tonicity inside the red blood cells increases due to the increase in
both HC03- and cr. This withdraws water from the plasma by osmosis
(= water shift). Consequently, the volume of the red blood cells and the
haematocrit mlue increa\·e slightly in the venous blood (see below).
6. The formed H. is efficiently buffered, so the blood pH drops onJy slightly
(from 7.-1 in the arterial blood lo 7. 36 in the venous blood).
Red cell Plasma A,·
---+L-1--~CO,
~----+....::.+-- o,
J;
'.
Figure 34: Tidal C02 excretion in the lungs. Notice reversal of the Cr shift.
I TIDAL C02 EXCRETION IN THE LUNGS I
When the venous blood reaches the lungs in the pulmonary artery (in
which the Pcm is 46 mmHg), it is exposed to the alveolar air in which the
Pc02 is lower (40 mmHg). Accordingly, the excess physically dissolved C0 2
diffu ses passively from the venous blood to the alveolar air under a pressure
gradient of 6 mmHg. The excess C02 in the carbamino compounds is also
dissociated and excreted 111 the all'eolar air
Also H. is released from H.Hb (see below) and binds to l r eo.~ · that
is obtained from KHCOJ, forming H2C03. The carbonic anhydrase enzyme
then catalyzes dissociation of H2C03 into water and CO.:, which is excreted
in the alveolar air. As a result, the HC03- concentration in the red blood cells
decreases, so HCO.;- d~ffuse from the plasma imo the red blood cells while
cr diffuse fro m rhe red blood cells to the plasma to maintain electric neutra-
lity, and thj s is sometimes called reversal of the chloride slzift (figure 34).
~ H .. is released from H.Hb due to 02 diffusion from the alveoli and form-
ation ofHb02. which is a weaker I-t" acceptor tlzan reduced Hh (page 74).
Hb02 then combines with the released K- tram KHC03 and forms KHb0 2 .
76
Chapter 7 co! transport (carriage) bi' the blood
~ About 200 ml COz are n ormally excreted I minute during rest be-
cause each I00 mJ blood supply 3. 7 ml C02 , and the pulmonary blood flow
(= cardiac output of the right ventricle) is about 5.5 litres I minute.
1. fhe HCoJ· concentration increases in both the red cells and the plasma.
2. fhe cr concentration increases in the red cells & decreases in the plasma
3. rhe tonicity inside the red cells increases due to accumulation ofboth cr
md HCoJ· . This leads to water movement from the plasma into the red
;ells by osmosis(= water shift), which results in .\ welling of the red cells.
The Peen in the venous blood is more than that in the alveolar air (about
46 and 40 rnmHg at rest respectively). Therefore, C02 diffuses passively
down this gradient from the venous blood to the alveolar air (to be eliminat-
ed in the expired air) and the chloride shift is rever!;ed (figure 34).
On the other hand, the Pen in the alveolar air is higher than that in the
venous blood (about I00 and 40 mmHg at rest respectively). Therefore, 02
diffuses passively down this gradient from the alveolar air to the blood and
combines with Hb, forming oxyHb.
75% HbO:z
30 40 50 60
P~(mm· Hg)
Point (A) represents the C02 conditions in the arterial blood at rest
(where the Pcm is 40 mml-Ig and the C02 content 49 ml I dL) whi le point
(V) represents the C02 cond itions in the venous blood at rest (where the
Pc02 is 46 mmHg and the C02 content 52.7 ml I dL).
The line that joins points (A) and (V) is the physiological C02 diss-
ociation cun•e. It represents the changes In Pcm and C02 content that occur
in the systemic blood as it flows from the arteries to the veins during rest,
and.from its extension upwards. the changes that would occ:ur when the C0 2
production increases can be predicted.
~ fhe exposure of blood to the high Pcm in the tissues shifts the 0 2-Hb
dissoci<ttion curve to the right (= Bohr's effect, page 70) i.e. facilitates Hb-
02 unloading, and this helps Hb-C02 1oading (= Haldane's effect). Conver-
sely, the ex_posure ofblood to the low Pco2 in the lun_gs shifts the 0 2-Hb dis-
sociation curve to the left i.e. facilitates Hb-02 loading, and this helps Hb-
C02 unloading. Therefore, the loading and unloading ofboth 0 2 and C02
are mutually-helpful (i.e. help euclr other) in both the lungs and tissues.
79
CHAPTERS
1. Breathing air that contains low 0 2 % than normal (e.g. in high altitudes).
2. Inadequate pulmonary ventilation (respiratory pump failure) : This re-
sults from defective breathing which may occur due to either :
a- Depression of the respiratory centre (e.g. in morphine poisoning).
b- Weakness or paralysis of the respiratory muscles (e.g. in poliomyelitis).
c- Fatigue of the respiratory muscles (e.g. in bronchial asthma).
d- Pneumothorax, hydrothorax, chest deformities and emphysema.
e- Shallow rapid breathing (e.g. in pulmonary congestion or embolism).
3. Gas e.xcltangefailure:This occurs in diseases that cause alveolo-capilla/y
block (e.g. diffuse pulmonary fibrosis and pulmonary edema) or ventila-
tion perfusion imbalance.
4. Rigltt to left cardiac shunts (e.g. atrial and ventricular septal defects) :
These transfer venous blood t o the left side of the heart (without oxygen-
ation in the lungs), resulting in hypoxaernia and consequently hypoxia.
l. Gen eralized (i.e. allover the body) e.g. in congestive heart failure, circul-
atory shock, and polycythaemia vera (refer to blood).
2. Localized e._g. in areas of venous thrombosis or V.C. (the latter is charac-
teristic of Raynaud's disease, in which severe V.C. occurs in the tips of
the lingers and roes, specially on exposure to cold).
81
Otapter 8 Hypoxia, acclimatization and c_yanosis
I Cyanide poisoning I
The cyanide salts block the cytochrome oxidase enzyme, so the cells
become hypoxic because they become unable to extract 0.2 from the blood.
The condition can be improved by hyperbaric oxygenation and also by giv-
ing methylene blue or nitrite salts (these substances convert Hb into metHb,
which reacts with cyanide and form the non-toxic compound cyan-metHb).
The following table shows the P02 and 0 2 content in the arterial and
venous blood in various types of hypoxia :
I SYMPTOMS OF HYPOXIA J
Sudden severe hypoxia is fatal due to deprerssion of the respiratory centre.
On the other hand, mild and moderate hypoxia lead to the following :
1. Nervous symptoms e.g. headache, fatigue, disorientation and drowsiness.
2. Digestive symptoms e.g. anorexia (loss of appetite), nausea and vomiting.
82
Chapter 8 Hypoxia, acclimatization and cyanosis
I ACCLIMATIZATION I
This term refers to the a dnptiH mechan isms t hnt occur in high altitudes
(i.e. 01 prolonged exposure to low 02 pressures). At high altitudes, the com-
position of air remains constant but its total pressure falls. This results in
markt•d reduction of the Pm in atmospheric air.
The minimal alveolar Pm that can be tolerated without loss of conscious-
ness •~ 40 mmHg(at which Jib is about 75% saturated with 02). The altitude
at wh1ch this occurs I'Gne.\ If the subject was breathing air, this P02 is rea-
ched when the atmospheric pressure decreases to 350 mmHg (at an altitude
of abcut 6100 meters) while if the subject was breathing I OIJ % 0 2. it is rea-
ched when the atmospheric pressure decrease~ to 120 mmHg (at an altitude
ofabout 13700meters)
small because the resulting hyperventilation washes C02 in the expired air
resulting in alkalosis (which tends to inhibit the respiratory centre). How-
ever, within a few days ventilation markedly increases due to :
a- Correction of the alkalosis through excessive excretion of HC03. by the
kidneys in the urine (so t he urine pH in high altitudes is alkaline) .
b- Stimulation qf the central chemoreceptors by the lowered brain pH
(which is produced as a result of development oflactic acidosis, as well
as shift ofHC03- from the brain to the plasma).
ln response to the low arterial P0.2, all the fo llowing increase in the cells :
a- The mitochondria (the site of oxidative reactions).
b- The myoglobin content in skeletal muscles.
c- The oxidative enzymes (specially the cytochrome oxidase enzyme).
84
Chapter 8 Hvpoxia, acclimatization and cyanosis
I CYANOSIS I
DEFINITION OF CYANOSIS I
Cyanosis is a blue discolouration of the skill and mucous mem branes
due to presence of an abnormally _great amount of reduced Hb in the super-
ficial .;apillaries. It is easily seen in the nail beds, mucous membranes. and
the areas that have thin skin e g. the ear lobes. lips and fingers
CAUSES OF CYANOSIS
1. Hvpoxic hypoxia (because both the arterial and venous blood contain
abnormallY _greater amounts of reduced Hb).
2. Stagnant hypoxia (due to much reduction ofHb in the venous blood).
3. Asphyxia
I
(in which there is both hy_poxia and hypercapnia).
I DEPTH OF CYANOSIS I
There is usually no relation between the severity of the condition and
the depth of cyanosis This is shown in the followin.g examples
1. In cases of hypoxic hypoxia, bleeding improves cvanosis (due to loss o~
reduced Hb) ~!though the condition becomes worser (due to loss ofHbOz)
2. In high altitudes, persons may be very deeply cyanosed although they livl
almost normally (because the blood contains sufficient amount s of oxyHb).
I TYPES OF CYANOSIS I
1. Central cyanosis : This is generalized (allover the body) and it occurs in
cases of hypoxic hypoxia that are due to central causes specially .
a- Cardiac diseases e.g. congestive heart failure and various septal defects.
b- Diseases that interfere with ventilation or ,gas exchan_ge in the lungs.
2. Peripheral cyanosis :This is localized to the areas of reduced blood flow
e.g. due to Y.C., as occurs in Rqy11aud's disea.'ie (page 80).
86
Chap'.;;.
e-. r-,~~----------H...v..,.p...o-'Xl-·a_,._a_c,_c_li_m_a...n..,·zg=ti-.o_
n-an
~d-.cv""'""a"'"n;..;.;o;.;.;.s=is
I OXYGEN THERAPY I
USES OF OXYGEN THERAPY IN HYPOXIA I
1. Ox ygen therapy is useful in cases of hypoxic: hypoxia, except in cases r?f
rig/11 to left cardiac shunts (page 79) in which blood bypasses the lungs
2. Ox ygen therapy is almost not mil!ful in anaemic:, stagnant and histotox ic
hypoxia, in which it only increases the physically dissolved 0 2 in the blood.
3. Ox ygen therapy improves cyanosis and is helpful in CO poisoning.
Under the normal atmospheric pressure at the sea level (= 760 mmHg),
the human body contains about l 000 ml of N: dissolved in the various body
fluids and tissues N 1 is an inert gus i.e. it plays no role in metabolism and is
neith< r utilized nor produced by the body. Its function is only to dilute atm-
osplzcric oxygen and to k eep the alveoli distended
Jne ofthe major problems that face divers is the high pressure of water
(abmtl atmosphere ei'<:'I:J' 10 meters of depth in sea water) which compre-
sses t'le chest and makes breathing difficult.
The increased Po2 and P-.:2 in the inspired air mcre~ses the dissolved
amou1ts of these gases m the body The disso.1,•ed 0: ;., tued by the tissue
while N~ is not u.\ ed ami remains dissoh•ed ifl t/tt; ti.\·.mes, specially the
adipo)e tissue (because N~ is 5 times more soluble in fat than m water). Thts
dissolved N2 may produce problems to the divers such as 11arcosis and de-
compression .<;ickne.\·.~ (sec below)
N2 and the trace gases (argo[\ krypton, neon. xenon and helium) are
physi J/ogical/y inert at the normal atmospheric pressure. However, under
high pressures, they exert an anaesthetic effect (probably by dissolving in
the nerve ceU membranes and affecting the ionic diffusion across them).
NITROGEN NARCOSIS I
This condition occurs when breathing llir at a pressure of 4 - 5 atmos-
phere•; i.e. at depths of J(J- 40 meters under sea water.The increased PN2 in
89
Chapter 9 Phvsiologv o{deep sea diving
Nitrogen narcosis can be avoided (and deeper dives can also be made)
by breathing mixtures of oxygen and helium . This is because helium is
less dissolved in the body fluids than N2 and also has a smaller molecular
weight (so it diffuses out from the tissues faster than N2 ) . However, it also
produces some ham'lful effects (see next).
DECOMPRESSION SICKNESS
CAISSON'S DISEASE, DYSBARISM OR BARO-TRAUMA
Explosive decompression
·"his is a severe (and oflen fatal) type of air embolism. It occurs when the
external pressure sud~enly ~rops from atmospheric to subatmospheric e.g. if
the wall of a pressurrzed arrplane (or a rock et) is broken at a ltiglt altitude
I AUTHOR'S AVAILABLE BOOKS I
1- Human physiology for mediCAl &Wdents : EndocrinP. glandc:; and repro-
duction.