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THE RESPIRATORY SYSTEM

 1 Introduction | 4
2 Anatomy | 5
3 Physiology | 14
4 Clinical aspects | 20
5 Respiratory system - Questions | 24

Infologic 1.7 3
| 1 | Introduction |

1 INTRODUCTION
This booklet summarises the respiratory
system with regard to the following topics:

anatomy

physiology

clinical aspects

4
 | Anatomy | 2 |

2 ANATOMY

2.1 RESPIRATORY ORGANS

The respiratory organs can be divided into:

upper airways
lower airways
lungs

The main role of the respiratory system is to

provide the body with oxygen and remove
carbon dioxide. The respiratory gases are
transported via the upper and lower airways The upper
to and from the lungs, where gas exchange airway
takes place.
The lower
airway
This gas exchange is the most important task
of the lungs. It involves oxygen moving from
the inspired air into the oxygen-depleted
venous blood and carbon dioxide moving in
the opposite direction so that it can be exhaled
from the lungs.
lungs

Both these processes take place via passive

diffusion, which means that the gases pass
through a membrane from one side where
Alveolus
there is a higher concentration to the other
~ 3 00
where there is a lower concentration.
m illion

5
| 2 | Anatomy |

2.1.1 ALVEOLI

In order for enough oxygen (around 200 ml

per minute when resting) to be taken up by
the body in this manner, the membrane needs
to be very thin (around 0.2 µm) and its surface
2
area large (between 50 and 100 m ). This huge
membrane area is accommodated within the
chest in the form of a massive number of tiny
units (around 300 million alveoli in each
lung).

The illustration shows the bronchioles and the alveoli. The bronchioles open into the alveolar
sacs, which are the smallest units in the lungs. The alveoli are surrounded by a network of
small blood vessels, or capillaries, which bring blood into contact with the alveolar walls for
the purpose of gas exchange.

2.1.2 THE UPPER AIRWAY

The nasal
cavity

Pharynx

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THE NASAL CAVITY
Clearing Heating
The nostrils contain hairs to filter the air and
remove larger particles. They are also rich in
superficial thin-walled blood vessels which
radiate heat that warms the inhaled air. The
air is warmed to a temperature of 32°C no
matter what the outside temperature is. At the
same time, the glandular secretions in the
nasal cavity humidify the air.
Breathing Swallowing
Soft palate
Epiglottis
| Anatomy | 2 |
Humidifying
THE PHARYNX
When swallowing, food is prevented from
entering the nasal cavity by a closing upward
movement of the soft palate in the roof of the
mouth. At the same time the epiglottis is
depressed to prevent food from passing into
the lower airways.
During mechanical ventilation of all kinds, this
part of the breathing process is bypassed,
which is why it is important that the inspired
air should be heated and humidified by other
means.
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| 2 | Anatomy |

2.2 THE LOWER AIRWAYS 2.2.2 THE TRACHEA

larynx The trachea is a tube-like portion of the

respiratory tract that connects the voice box
trachea with the bronchi.
bronchial tree After passing the vocal cords, the air stream
enters the trachea, which in adults is a 10-12
cm long tube that is 20-25 mm in diameter. It
is kept open by horseshoe-shaped rings of
Larynx
cartilage, where the opening is at the back.

During anesthesia, an endotracheal tube is

sometimes inserted into the trachea to
Trachea guarantee a free airway. This is also the site
of the procedure known as tracheotomy,
which is performed by paramedics, emergency
physicians and surgeons in order to secure
an airway in case of obstruction. It opens a
direct airway through an incision in the
Bronchial tree windpipe or trachea between its upper rings.

The mucous membrane of the trachea is

covered with microscopic hairs or cilia, which
transport mucus and inhaled foreign bodies
upward to the laryngeal opening, where they
2.2.1 THE LARYNX
are either coughed up or swallowed.
The larynx, which is also known as the voice
box, is a 2-inch long, tube-shaped organ.

The larynx is the portion of the respiratory

tract containing the vocal cords, which
produce sound. It is located between the
pharynx and the trachea and part of it is visible
from the outside in men as the Adam’s apple.

After passing through the nasal cavity and

pharynx, the inhaled air reaches the larynx,
which is partly covered by the epiglottis,
which covers its upper opening completely
during swallowing, as shown earlier. The vocal
cords are also closed during swallowing.

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 | Anatomy | 2 |

2.2.3 THE BRONCHIAL TREE

This consists of the:

primary bronchi
Upper lobe

stem bronchi
Middle
lobe
lobar bronchi
Lower
bronchioles lobe

Both lungs are enveloped by their pleural

membranes. The inner pleural membrane
covers the surface of the lungs, and the outer
pleural membrane covers the inside of the
chest wall and the diaphragm (the most
important respiratory muscle). In the potential
space between the two membranes, there is
a constant negative pressure.
The trachea divides at a point called the
carina into two primary bronchi (right and Inner
left). These then branch off into lesser and (pulmonary)
pleura
lesser bronchi until they terminate, after some
20-30 divisions, in the alveoli. Like the Pleural
cavity
trachea, the bronchi and bronchioles are
covered in cilia. Outer (parietal)
pleura

2.2.4 THE LUNGS

The lungs are divided into lobes - where the

left lung has two and the right lung has three. 2.3 THE MECHANICS OF
The lobes then divide into segments, which BREATHING
in turn divide into lobules, each of which is
supplied by one bronchiole. 2.3.1 INSPIRATION

Inspiration is an active movement. The most

important respiratory muscle is the
diaphragm, a flat domed sheet of muscle
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| 2 | Anatomy |

attached to the lower ribs. On inspiration, the

diaphragm moves downwards as it flattens
out. It moves around 1 cm during a normal
breath, but can move up to 10 cm if
necessary.

External
intercostal
muscles

Diaphragm
Other muscles that contribute to inspiration
are those which are attached to the outer
surface of the ribs. They are known as the
external intercostal muscles, and they lift
the chest wall upwards and outwards. The
pressure inside the lung then falls below the
atmospheric pressure, causing air to move
downwards to the alveoli.
If expiration is obstructed for any reason, the
abdominal muscles and the muscles
attached to the inner surface of the ribs,
known as the internal intercostal muscles,
help to draw the chest wall downwards and
inwards to expel the air.
When the body is resting, the work of
breathing is normally very little. Under
pathological conditions, however, it may
increase considerably. During controlled
mechanical ventilation, the work of breathing
is performed by the ventilator.

2.3.2 EXPIRATION

Expiration is normally passive: when

intrapulmonary pressure exceeds atmospheric
pressure, air is driven out of the lungs by the
elastic recoil of the lungs and chest wall as
they return to their original position after
inspiration.

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 | Anatomy | 2 |

2.3.3 PRESSURE CHANGES

The difference between intrapulmonary and
intrapleural pressures is normally 8 cmH2O.
When a mechanical ventilator is used or when
ventilation is manually controlled, positive
pressure is applied to the air or gas mixture
delivered to the patient. The pressure in the
lungs during inspiration is higher than the
atmospheric pressure and both intrapulmonary
and intrapleural pressures are on average
higher than during spontaneous breathing.

Pressure (kPa)
Intrapulmonary
pressure Time (s)
0

Intrapleural pres-
-1 sure

Insp Exp Insp Exp

Spontaneous breathing

Pressure (kPa)

1
Intrapulmonary pressure
Time (s)
0

Intrapleural pressure
-1

Insp Exp Insp Exp

Controlled ventilation

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| 2 | Anatomy |

2.3.4 LUNG VOLUMES

Volume (1)
6 IRV IC VC TLC

VT
3
ERV
2

FRC RV
1

0
Time

Static lung volumes

TYPICAL ADULT VALUES FOR A FEW KEY RESPIRATORY PARAMETERS

Respiratory parameter Explanation Adult values

VT (Tidal Volume) The volume of a normal breath (both inhaled 500 ml (½ liter)
and exhaled)

VC (Vital Capacity) The volume change between maximal 3 500 ml (3½ liters)
inspiration and maximal expiration

IRV (Inspiratory Reserve The volume that can still be inhaled after 2 000 ml (2 liters)
Volume) a normal breath

ERV (Expiratory Reserve The maximum volume that can still be 1 000 ml (1 liter)
Volume) exhaled after a normal breath

RV (Residual Volume) The volume left in the lungs after forced 1 500 ml (1½ liters)
expiration

FRC (Functional Residual The volume of air in the lungs at the end 2 500 ml (2½ liters)
Capacity (ERV+RV)) of a normal exhalation

TLC (Total Lung Capacity) The volume of air that the lungs contain 5 000 ml (5 liters)
after maximal inspiration

MV (Minute Volume) The minute volume is the volume of air 6 000 ml (6 liters)
breathed in and out of the lungs in a
minute = VT x respiratory rate

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 | Anatomy | 2 |

TYPICAL PEDIATRIC VALUES FOR KEY RESPIRATORY PARAMETERS

Variable Infant Adult Children also desaturate rapidly because of

increased oxygen consumption per kilogram.
Respiratory rate (b/min) 30 - 50 12 - 16
In addition, their FRC is lower during
Tidal volume (ml/kg) 6-8 7
anesthesia due to small alveoli and a very
Dead space (ml/kg) 2-2.5 2.2 compliant chest wall (unlike the more rigid
Alveolar ventilation (ml) 100-150 60 adult chest (see "Compliance"). This also
FRC (ml) 27 - 30 30 increases atelectasis or collapse of the alveoli.
Oxygen consumption (ml) 6-8 3

In infants and children, minute volume is

increased, as is respiratory rate. Tidal volume
and dead space are equivalent to adults on a
per kilogram basis.

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| 3 | Physiology |

3 PHYSIOLOGY
Respiration can be divided into four
3.1 RESPIRATION sub-processes:

Respiration is the overall process whereby
oxygen is taken up by the body and carbon
dioxide is eliminated.
The respiration rate varies (Adults: 12-15
breaths/minute and newborn babies: 30-40
breaths/minute).
Ventilation, which involves the transport of
air in and out of the alveoli.
Passage over the alveolar membrane,
which involves the exchange of oxygen and
carbon dioxide between air and blood.
Circulation-perfusion, which involves the
transport of oxygen from the pulmonary
capillaries to the body’s tissues.

Cellular respiration, which involves the

O2 transport of oxygen to and carbon dioxide
CO2 from the individual cells.

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 | Physiology | 3 |

3.2 VENTILATION
3.2.1 REGULATION OF BREATHING

The volume and frequency of breathing are

The respiratory governed by impulses from the respiratory
center and
central receptors center in the medulla oblongata to the
respiratory muscles, i.e. the diaphragm.

These impulses are in turn governed by

information from different receptors in the
body – central ones close to the respiratory
Peripheral center and peripheral ones in the carotid
receptors
arteries. Receptors are sensory nerve terminals
which respond to stimuli of various kinds.

NORMAL REGULATION OF BREATHING

Receptors Signal to the Muscular activity

respiratory center
The blood
Central Low pH Hyperventilation
PaCO2
Peripheral High pH Hypoventilation

In normal breathing, the impulses from the
central receptors depend mainly on the carbon
dioxide level in the blood, expressed in the
diagram as PaCO2. This affects the pH value
in the cerebrospinal fluid surrounding the
brain and spinal cord.
In turn, this has a direct effect on the
respiratory center in that a low pH (high CO2
level) stimulates breathing, while a high pH
(low CO2 level) inhibits breathing. The
peripheral receptors are also affected by the
blood pH value so that low pH stimulates
breathing.

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| 3 | Physiology |

REGULATION OF BREATHING IN A PATIENT WITH CHRONIC LUNG DISEASE

Signal to the
respiratory center Muscular activity
The blood Receptors Hyperventilation
Low PaO2
PaO2 Peripheral
High PaO2 Hypoventilation

In patients with chronic lung disease, for example, Chronic Obstructive Pulmonary Disease
(COPD), the sensitivity of the respiratory center to high PaCO2 decreases with time. Respiratory
impulses are governed instead, via the peripheral receptors, by the oxygen level in the blood
which is expressed in the diagram as PaO2. When PaO2 falls to a level of around 8 kPa, the
respiratory center is stimulated.

Physiological dead space is the sum of the

3.2.2 KEY CONCEPTS IN VENTILATION two and in an average 70 kg adult, it will be
around 140 ml, or just under one third of a
DEAD SPACE normal breath. A patient with increased
alveolar dead space, for example, might be
Dead space is the volume in which no gas
suffering from severe chronic obstructive
exchange takes place.
pulmonary disease

Anatomical
dead
space
Physiological
dead space
+ Pulmonary
embolus = ~ 2 m l/kg body w e ight
or
~ 80 ml/m2 body surface

Anatomical dead space + alveolar dead space = physiological

dead space

Anatomical dead space is the volume of the

conducting airways of the nose, mouth and
trachea down to the level of the alveoli,
representing the portion of inspired gas
unavailable for exchange of gases with
pulmonary capillary blood.

Alveolar dead space is the volume of gas

reaching non-perfused or poorly perfused
alveoli. This is minimal in healthy,
spontaneously breathing individuals, although
positive pressure ventilation and various types
of lung disease can increase it.
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COMPLIANCE
A.
Change in volume (ml)
Change in pressure (kPa)
B.
Compliance is a measure of the elasticity of
the lungs and chest wall. It denotes the
change in volume produced by a unit change
in pressure. Like balloons, lungs may be more
or less difficult to inflate. High compliance
means reduced elastic resistance during
inspiration and decreased expelling force
during expiration. Patients with “stiff” lungs
have a reduced compliance value. Three of
the most important examples here are
pulmonary edema, Acute Respiratory Distress
Syndrome (ARDS) and severe pneumonia,
| Physiology | 3 |
RESISTANCE
The airways have a tendency to hinder the
passage of air so a certain pressure is required
to deliver gas to the alveoli.
A.
B.
A. Laminar flow (low resistance) and B. Turbulent flow (higher
resistance)
Resistance is determined by the properties of
the airway and by the type and speed of flow.
Resistance is the impedance to gas flow in
the airways, which present a resistance to
flow. This is expressed as pressure divided by
gas flow and is measured in kPa/l/s. It is
calculated as propelling pressure (kPa) divided
by gas flow (l/s). Increased resistance is seen
in patients with COPD.
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| 3 | Physiology |

GAS EXCHANGE, GAS TRANSPORT AND

CELLULAR RESPIRATION

Pulmonary capillary
Alveolus
Hb
O2

HbO2
Artery

O2

Oxidation Cell
Tissue capillary
CO2
H2O

HHb
Vein

CO2 Alveolus

Pulmonary capillary

Both oxygen and carbon dioxide diffuse

passively over the alveolar membrane
(although in different directions) because of
the difference in concentration on either side.
Oxygen passes into the pulmonary capillaries
where it combines with the hemoglobin of the
red blood cells and, via the circulation, is
transported to the body’s various tissues.

There the oxygen is released from the

hemoglobin and diffuses into the
oxygen-depleted cells. These cells use the
oxygen for their oxidative processes,
producing carbon dioxide and water. In
principle, the carbon dioxide then takes the
reverse journey back to the alveoli, where it is
breathed out.

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 | Physiology | 3 |

3.3 CARBON DIOXIDE

3.3.1 THE CARBON DIOXIDE (CO2)
BALANCE

Carbon dioxide is one of the end products of The carbon dioxide balance is dependent on
metabolism and is important to the breathing four main factors:
process in that its level regulates normal
healthy breathing. CO2 production
Transportation
Storage
Elimination

1
2
Energy CO2 Water
To the blood In the blood

plasma
red
blood H2CO3
cell HCO3
HHB
CO2
Nutritive O2
substance
membrane
low PCO2 high PCO2

CO2 production Transportation

3 4

O2
CO2

Storage Elimination

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| 4 | Clinical aspects |

4 CLINICAL ASPECTS
Pressure
In this section a few clinical aspects will be
mentioned briefly including: Controlled

Some differences between spontaneous

and controlled ventilation. time

Respiratory disease and pathological

processes. Insp. Exp. Insp. Exp.

Controlled ventilation

4.1 SPONTANEOUS AND

CONTROLLED VENTILATION
We have already seen that both
intrapulmonary and intrapleural pressure are
higher when a ventilator is used than when
breathing is spontaneous. Alveolar dead space
may also be increased by positive pressure
ventilation.

Pressure
Spontaneous

time

Insp. Exp. Insp. Exp.

Spontaneous ventilation

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 | Clinical aspects | 4 |

4.2 RESPIRATORY DISEASE AND

PATHOLOGICAL PROCESSES
Both acute and chronic respiratory disorders
may have negative effects on the various
processes involved in breathing, as well as on
its regulation.
We have also seen that lung disease affects
the regulation of breathing in that impulses to
the respiratory center are governed by levels
of oxygen rather than by levels of carbon
dioxide. Different disorders may have different
effects on the processes involved in breathing,
as illustrated in the following illustrations.

Signal to the
respiratory center Muscular activity
The blood Receptors Hyperventilation
Low PaO2
PaO2 Peripheral
High PaO2 Hypoventilation

Regulation of breathing in a patient with chronic lung disease

4.2.1 LUNG DISEASE AND VENTILATION

Respiratory diseases are often divided into two main types – restrictive and obstructive. The
former often include elements of the latter. They have a direct effect on ventilation capacity.

Maximal inspiration
and expiration
Hyperventilation

1 sec

Volume (l)
4

0
Time (s)

Normal ventilatory capacity

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| 4 | Clinical aspects |

4.2.2 RESTRICTIVE DISEASE

In restrictive lung disease, expansion of the
lungs during inspiration is restricted (hence
the name), leading to a reduction in total lung
capacity. To compensate, the patient will often
increase his or her respiratory rate, since small
breaths are less demanding in terms of work
of breathing.
Examples of restrictive conditions are those
that produce ”stiff” lungs, such as severe
pneumonia and pulmonary edema.
Tuberculosis and silicosis are rarer conditions
that are also restrictive, although tuberculosis
is now on the increase again in many parts of
the world. Severe obesity may also restrict
diaphragm movement.

Volume (l)
2

0 Time (s)

Restrictive lung disease

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 | Clinical aspects | 4 |

4.2.3 OBSTRUCTIVE DISEASE

The obstruction of the airways for which The various forms of obstructive lung disease
obstructive disease is named makes it difficult include asthma, chronic bronchitis and
for patients to empty their lungs properly, emphysema. Smoking is implicated in many
causing problems during expiration. Patients obstructive conditions.
with moderate obstructive disease generally
choose a low respiratory rate, since prolonged
expiration (low flow) is less demanding in
terms of work of breathing.

These patients often have some hyperinflation

of the lungs due to air trapping. When the
obstructive element becomes more severe
and hyperinflation increases, patients are
forced to choose a high respiratory rate,
leading to heavier work of breathing and
ultimately to respiratory failure.

Volume (l)
4
3

2
1
0
Time (s)

Obstructive lung disease

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x
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