8/15/2022

Goal of Respiratory Therapy

• Get oxygen to the cells and remove CO2
• Important facts to remember – gas always
takes the path of least resistance and flows
from a higher pressure to a lower pressure.

Introduction to the
Respiratory System
• Primary function is the absorption of O2 and excretion of
CO2 called “external respiration”

• “Internal respiration” gas exchange between tissue cells

and systemic capillary blood

• During a lifetime, about 250 million liters partake in

external respiration.
– Performed with minimal work

• Secondary function: filters both inhaled contaminants and

small clots or chemicals from blood

Development of the Respiratory

System
• Extends from almost conception into childhood.

• During Canalicular phase, life becomes possible.

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Embryonic Period

• 0-6weeks
• Lung Buds Appears followed by 2 branches
• Airway Branching begins
• Diaphragm begins to develop

Pseudo glandular Period

• 7-16 weeks
• Branching continues to terminal bronchi
• Mucus glands form
• Diaphragm develops
• Cilia cells appear

Canalicular Period
• 17-26 weeks
• Airways increase in length and diameter
• Formation of Alveolar ducts
• Appearance of Type I and Type II cells
(immature surfactant)
• Pulmonary capillaries proliferate

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Terminal sac and Alveolar Period

• 27 weeks to 8 years old
• Appearance of Alveoli
• Merger of alveolar epithelium and
pulmonary capillaries
• Appearance of mature surfactant
• Alveoli increase in size and number

Chest Wall Development,

Diaphragm and Lung Volume
• Infant thorax is more compliant than that of an adult.

• FRC is established by the equal and opposing forces of

chest wall to expand against the lungs tendency to
collapse.
. .
• The infant’s more compliant thorax results in lower FRC
and TLC.
– Predisposes infant to early airway closure, atelectasis, V/Q
mismatch, and hypoxemia
– Combated by ending expiration early, results in gas
trapping, narrowing the glottis, back pressure
• Patient will make a grunting sound

Fetal Lung Development

• At end of Canalicular phase, primitive acini form,
covered with type I and II pneumocytes.
– Life viable if airway, MV, surfactant provided

• During terminal saccular stage more acini form.

– There is thinning of the type I cells
– Type II cells mature and produce surfactant.

• Alveolar stage begins at about 32 weeks.

– Mature alveoli/capillary membranes appear.

• At birth, about 50 million alveoli are present.

– By age 8, there will be about 300 million.

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The Fetal Lung

• Lung maturation is determined by surfactant.
– Phosphatidylcholine levels predictive
• Lecithin/sphingomyelin ratio (L/S ratio)
• Phosphatidylglycerol (PG) concentration

• Fetal lung fluid is constantly produced

– Slight positive pressure keeps lungs inflated.
• Promotes normal lung development
• At birth, lungs hold about 40 ml of fluid.
• If deficient, can result in hypoplastic lung

Lymphatic and Nervous

Development
• Lymph nodes and vessels are located in connective tissues
beside pulmonary structures
– Provide fluid control and defense
• Absorbed fluid travels to hilar lymph nodes

• Nervous tissue development

– Brainstem centers for automatic control
– Phrenic and intercostal nerves form to carry motor signals to
diaphragm and intercostal muscles
– Autonomic fibers form for smooth muscle control

Vascular Development
• Basic structure is in place at birth.

• Subsequent vascular growth involves increased smooth

muscle growth and increased density of arterioles and
capillaries in distal regions.

• Lungs are unique as blood from RV and LV provide flow

to alveoli microcirculation.
– Pulmonary circulation from RV
– Bronchial circulation from LV
– Provides greater stability and resistance against the impact
of disease processes

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Postnatal Upper Airway

• Head flexion can cause airway obstruction.

• Factors contributing to airway obstruction

– Tongue is relatively larger compared with adults.
– Nasal passages are relatively smaller.
• Most infants nose breathe exclusively.
• At 4 to 5 months, most infants can breathe orally.
– Infections or Intubations can cause obstruction at the cricoid
cartilage (narrowest point) or the epiglottis, which is relatively
longer and less flexible than that of an adult.

Fetal Circulation (cont.)

• In utero fetal lungs have high PVR due to low PAO2.
– Ductus Arteriosus shunts blood from high-resistance
pulmonary artery to low-resistance aorta.

Fetal Circulation
• Placenta large volume, low resistance system, so fetal
SVR is low

• Umbilical vein returns oxygenated blood from the

placenta to fetus via the Ductus Venosis.

• Flows into the IVC and on to the RA

• Oxygenated blood is preferentially shunted through the

foramen ovale from the right to the left atrium.
– Provides oxygenated blood to systemic circulation

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Uterine Life
• In utero life depends on placental structure, which
provides, among many things:
– Gas exchange
– Nutrients and waste removal
– Defense against disease

• Fetal circulation incorporates the placenta by the

umbilicus and use of three special shunts:
– Ductus Venosis, Ductus Arteriosus, and foramen ovale

Uterine Life (cont.)

Placenta
• Source of gas exchange for fetus
• Gas exchange occurs at between chorionic
villi known as intervillous space
• Blood comes to the placenta via the 2
umbilical arteries
• Oxygenated blood leaves placenta via the
umbilical vein

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Umbilical Chord
• Contains 2 umbilical arteries and one
umbilical vein
• Wharton Jelly is between vessels to provide
support

Functions of Amniotic Fluid

• Protection from traumatic injury
• Thermoregulation
• Facilitation of fetal movement
• Normal Fluid level 500 to 1500 ml

Polydramnios
• Too much amniotic fluid > 2000ml
• Indicates a problem with swallowing
mechanism of fetus – CNS Malformation,
cleft palate, Downs syndrome, congenital
heart disease

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Oligohydramnious
• Too little amniotic fluid
• Due to defect in urinary system

Blood gas values in Utero

• Umbilical Artery • Umbilical Vein
• pH 7.33 • pH 7.35
• PCO2 46 • PCO2 42
• PO2 16 • PO2 29

Low Oxygenation
• Diffusion Limitation
• Shunts
• Oxygen consumption of Placenta
• Fetal HB high affinity for Oxygen results in
higher Sat with lower PaO2

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Cardiopulmonary Events at Birth

• Fetal lung fluid
– Prior to birth, production stops and absorption starts.
– One third of fluid is expelled by vaginal squeeze.
– Pulmonary lymphatics absorb remaining fluid.

• Tactile and thermal stimuli initiate first breath.

– Initial breath requires trans pulmonary pressures >40 cm
H2O.
– Subsequent breaths require progressively less pressure as
lung volume increases.

Cardiopulmonary Events at Birth

(cont.)
• Air in lung increases PO2 and pH, while PCO2 decreases,
which results in:
– Pulmonary vasodilation and decreased PVR
– Ductus arteriosus constriction/closure
– Increased pulmonary blood flow

• At the same time, placenta removal results in:

– Sudden increase in SVR

• Net results:
– LAP > RAP, so foramen ovale closes
– Transition to extra uterine circulation complete