SESSION 1

ANATOMY OF THE RESPIRATORY SYSTEM

In the figure facing, we can see the sagittal section of the upper airway. In this form, the position
of the frontal, ethmoidal, and sphenoidal sinuses and the passage of air through the nose and
mouth to the trachea are important.

UPPER AIRWAY:
It is a path for air flow, air filter, heating
and humidification, sense of smell and
taste, speaking and protection of the
lower air duct.

Application: Sinusitis
It is one of the common diseases that is known as a
complication of colds and can be seen in both acute and
chronic forms. The four important sinuses in the cranial
bone, which are named according to the bone in which
they are located, are: frontal, maxillary, ethmoidal and
sphenoidal.
The best diagnostic method for sinusitis, in addition to
history and physical examination, is CT scan.

EXERCISE INDUCED ASTHMA(BRONCHOSPASM)

People experience shortness of breath, wheezing and coughing when exercising in the cold
outside, which is more common in people with asthma. This phenomenon is called sports asthma.
The mechanism of sports asthma: the cause of sports asthma are reflexes that start from the
stimulation of receptors in the large airways (upper airways, trachea and main bronchus).
The main task of the upper airways, trachea and main bronchus is to pass inspiratory air. Also,
these paths play a role in heating, humidifying and filtering the respiratory air. During inhalation,
water vapor is separated from the layer of water covering the airways and absorbed into the
inhaled air to warm and humidify it. This layer of water is made again by the cells of the airways.
During exhalation, as the air leaves the breathing apparatus and cools down, some water vapor is
taken from the exhaled air, but a small amount of water vapor is expelled along with the exhaled
air. The rate of water removal in this way is normally very low. During exercise, water excretion
increases due to increased ventilation. As a result, in people with sensitive lungs, due to the lack of
water and heating of inhaled air, the mucus becomes dry and irritated and causes an asthmatic
reaction with symptoms of shortness of breath, wheezing and coughing. Cold and dry weather
aggravates this situation.
These people are advised to maintain the humidity of their airways and not exercise in cold and
dry weather, and the best exercise for them is swimming. They can also use corticosteroid
inhalation, which significantly reduces symptoms.

Examination and anatomy of the pharynx:

During the examination, we examine the throat for hard and soft palate, small tongue and tonsils.
Application: Some patients have respiratory failure and need intubation. In this case, should we
examine the throat to determine if intubation is difficult or not? That is, if hard and soft palate,
small tongue and base of the tongue are seen during the examination, it will probably be easy to
repent of that person. But if the patient was obese or had a short neck or part of the soft palate
could not be seen, it would be difficult to convert him. Examination of the pharynx can be used to
check upper respiratory tract infections and cases such as sore throat. We also examine post nasal
discharge (PND) in patients with sinusitis.

Examination and anatomy

of the larynx and trachea
In the figure, from top to bottom,
hyoid bone, thyrohyoid
membrane, thyroid cartilage,
Crico's ligament, respectively.
Thyroid, cricoid cartilage,
cricotracheal ligament and c-
shaped tracheal cartilages are
located.
Application: Tracheostomy
In patients who are in the ICU for
a long time and cannot separate
the devices for 2-3 weeks, we
perform a tracheostomy (between
the first and second or second and
third cartilages of the trachea).
OBSTRUCTIVE SLEEP APNEA:
Interruption of breathing during sleep is due to disorders in the anatomical structure of the upper
airways or the use of some drugs.
The mechanism of respiratory apnea during sleep: during sleep, the tonicity of the muscles of the
upper airways is reduced, which leads to the partial closure of the airways. Narrowing of the
airways causes snoring. As the sleep deepens, the muscle tone is completely lost, which causes the
airways to be completely closed, finally, the path of air entering the lungs is blocked and the
person suffers from hypoxia.
After enduring 10 second in hypoxia condition, by making the person's sleep lighter or waking him
up, the patient takes a deep breath to get the body out of the hypoxia condition. But when the
person sleeps, the above events are repeated again, which causes the person to wake up several
times and not have a good night's sleep. This interrupted sleep causes fatigue and stimulation of
the autonomic nerves, resulting in an increase in heart rate, which can cause heart arrhythmia and
high blood pressure resistant to treatment in the long run.
In general, apnea and snoring are usually due to the narrowing of the airway in the oropharyngeal,
back of the palate, and hypopharyngeal region, which occurs in obese people with short necks,
large soft tongue and palate, and micrognathia (small chin).
Note: If breathing stops completely, it is called apnea, and if breathing is not stopped completely,
it is called hypopnea.
By calculating the total number of times of apnea and hypopnea in one hour of a person's sleep,
the hypopnea apnea index is obtained, which should normally be less than 5. The division of values
greater than 5 is as follows:
5 <mild< 15 - 15 <moderate< 30–sever >30

5 <mild< 15 - 15 <moderate< 30 – sever >30

When passing through the larynx to perform

bronchoscopy, we encounter the following
structures: epiglottis, true vocal cords, false
vocal cords (vestibular), cuneiform and
corniculate cartilages.
In order for the airways to remain open, the
position of the head is important in such a
way that if the person's head is flexed, the
airways are closed. Therefore, when
intubating in the trachea, put the person's
head in the extend position so that
intubation can be done more easily.
Histologically, the chip, from the inside
to the outside, includes:
1) Mucous, which includes respiratory
epithelium and lamina propria.
2) Submucosa, which contains
submucosal glands.
3) Tracheal-shaped hyaline cartilages
that are not located in the posterior part
(adjacent to the esophagus) and instead
of them, there is a series of smooth
muscles.
4) Advantis

Anatomy of carina, main, lobular and segmental

bronchi
Carina is where the trachea bifurcates into two main right
and left bronchi.
According to the figure, the angle between the right main
bronchus and the vertical line is about 20-30 degrees, and
the angle between the left main bronchus and the vertical
line is 45-55 degrees. Due to the greater alignment of the
right main bronchus with the trachea, the probability of a
foreign body entering this bronchus is higher than the left
bronchus (this condition is called aspiration pneumonia,
which is more common on the right side).
Application: During intubation, the appropriate place for placing the end of the tube is about 3-5
cm above the carina. Now, if the tube goes lower, due to the low angle of the right bronchus
compared to the trachea, the tube enters the right bronchus, as a result, only the right lung is
ventilated and the left lung is not ventilated.
Therefore, to ensure the placement of the end of the tube, we auscultate the right and left lungs.
If we hear a sound only in the right lung, it means that the tube has entered the right bronchus
and only the right lung is ventilated, which causes a drop in blood oxygen, but if the sound is heard
in both lungs, the location of the tube is suitable. For example, in a person weighing 70 kg, about
24 cm below the lower lip is a suitable place for the end of the tube.
In the past, the ABC order (in the order of airway, breathing and circulation) was used in the
resuscitation of a patient with respiratory failure. Today, this arrangement has been changed to
CAB. It means that blood flow should be provided first by cardiac massage and then the airway
should be maintained, one of which is intubation.
The right lung has three lobes, and for this reason,
the right main bronchus is divided into three
branches of the lower-middle-upper lobe bronchus.
The left lung has two lobes and therefore the left
main bronchus is divided into two branches of the
lower-upper lobe bronchus. The left bronchus has a
lingual branch instead of the middle branch of the
right bronchus.
Next, each of the lobes of the lung are divided into
segmental bronchi, as a result, each of the lobes of
the lung is divided into a number of segments, the
number and name of each of which is as follows:
• Right upper lobe • Left upper lobe (upper division)
o 1.Apical o 1,2.Apical (posterior)
o 2.Posterior o 3.Anterior
o 3.Anterior • Lingula (lower division)
• Right middle lobe o 4.Superior lingula
o 4.Lateral o 5.Inferior lingula
o 5.Medial • Left lower lobe
• Right lower lobe o 6.Superior
o 6.Superior o 7,8.Anterior basal
o 7.Medial basal o 9.Lateral basal
o 8.Anterior basal o 10.Posterior basal
o 9.Lateral basal
o 10.Posterior basal

→ Law 60/40: It is believed that the

ventilation capacity of the right lung
is 60% and the left lung is 40%, which
can be attributed to the position of
the heart and the presence of an
excess middle lobe in the right lung.
According to the opposite figure, the
mentioned division is illustrated
 Examining the lung from different
views

1) Anterior view: according to the shape,

the upper and middle lobes of the right
lung and the upper lobe and lingula of the
left lung can be heard better, and only the
8th segment can be seen from the lower
lobe.
2) Posterior view: In pulmonary
auscultation, from this view, segments of
the lower lobe and parts of the upper lobe
can be heard. So this view cannot be a
suitable place for auscultation of the
middle lingula lobe.
3) Lateral view: only the right and left
lungs of our dog cannot be heard.

Histology and anatomy of bronchioles and terminal ducts

As a result of dividing the segmental bronchi, smaller bronchi and bronchioles are obtained in the
next stage. Bronchioles have the following layers in terms of histology:
1) mucosa:
a. The layers containing mucus
include two layers, gel and sol,
where the cilia move, which causes
the gel layer to move to the upper
parts.
b. ciliated and goblet cell epithelium
c. Basal membrane
d. Almina propria
2) Submucosa (contains glands that
open to the mucous epithelium layer
and smooth muscle (there is no
more cartilage in the bronchioles)
3) Advantis
According to the figure below, the order of division of ducts after the segmental bronchus includes
small bronchus, bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts and
alveolar sacs.

Summary: From the beginning of the trachea to the end of the bronchiole is called the conducting
zone, which is only for conducting air, and there is no exchange in this area, and it includes
generation 0 to 16. Finally, from the respiratory bronchiole to the alveolar sac. is called the
respiratory zone, which is a place for gas exchange and includes from generation 17 to 23.

Along with each terminal bronchiole, a

vein and a pulmonary artery enter,
which are collectively called a
bronchovascular bundle.

In this figure, you can see another

view of the division of the end ducts.
Atrium is located in the space
between two alveolar sacs. There are
also holes for air communication
between alveolar sacs
 Alveolus
In the wall of the alveoli, the following
structures are observed:
1) Nomocyte (respiratory epithelial) cells exist
with two cell types,
a. The first type covers the alveolar and
structural surface.
b. The second type is the manufacturer of
surfactant, which is characterized by a large
nucleus, a developed Golgi system, and a
lamellar body (origin of surfactant). Surfactant
reduces surface tension.
2) Next to the respiratory epithelium, interstitial tissue, which contains connective tissue, is
observed.
3) Blood vessels with an endothelial wall and containing erythrocytes are seen.
4) The wall contains holes called Kohn's holes.
5) There are a number of macrophages inside the alveoli.
Oxygen must pass through the respiratory epithelium, connective tissue and endothelial cells of
the vessel wall to enter the erythrocytes.
Law 30:30: In a patient who is intubated for breathing and artificially ventilated, two points should
be taken into account:
▪ Airway pressure should not be more than 30 mmHg, otherwise it will cause barotrauma
(damage due to high pressure). For this purpose, the volume of flowing air is adjusted
between 6-8 ml/kg.
▪ Blood pressure in the pulmonary vessels should not exceed 30 cmH2O.

Diagnosis of lung diseases

CT scan can be used to diagnose lung
diseases. In this method, for a better
understanding, the secondary lobule
should be used as the structural and
functional unit of the lung. The structure
of a secondary lobule of the lung,
according to the figure, includes:
1) An end bronchiole which is also called
lobular bronchiole.
2) An artery next to the bronchiole that
carries dark blood for gas exchange. (It is
seen in blue color in CT images)
3) connective tissue or interlobular septum that surrounds the secondary lobule and separates it
from other lobules.
4) A vein containing bright blood located inside the interlobular septum (secondary lobule wall). (It
is seen in red in CT images).
5) There are two types of lymphatic system here: one is the lymph that is in the interlobular
septum and the other is the lymph that is in the bronchovascular bundle. (It is seen in yellow in CT
images). The lymphatic system of the interlobular septum is called the perilymphatic region.
6) The terminal bronchial and artery are located in the center of the secondary lobule.

Some of the diseases that can be seen include:

1) Involvement of the centrilobular area in the middle of the
lung, which can be seen in blue color, such as respiratory
bronchiolitis, allergic pneumonia and emphysema.
2) Involvement of the perilymphatic area around the lobule,
which is seen in yellow and indicates the involvement of the
lymphatic system, for example, when lung cancer spreads
through the lymphatic system, which is called carcinomatous
lymphangitis and is accompanied by thickening of the
interlobular septum. Also, in pulmonary-cardiac edema, the
perilymphatic region is involved and the interlobular wall is
thickened.

Physiology of respiration
VENTILATION
The movement of air in and out of the lungs is called ventilation, which is part of the breathing
process. Respiration includes two components:
▪ Breathing at the alveolar level: exchange of O2 and CO2 between blood and air, which is
called ventilation.
▪ Respiration at the cellular level: exchange of O2 and CO2 between blood and tissue.
 Define multiple parameters
TV division: from 500 ml of tidal volume
(Tidal Volume) in a normal person, 150 ml
remains in the dead anatomical space and
350 ml reaches the alveoli. Therefore, the
alveolar volume is about 2 times the
anatomical dead air.
Note: The deeper and slower the
breathing, the lower the proportion of
dead air.
VE: If a person breathes 15 times per minute, and each time 500ml of current volume enters his
lungs, his minute ventilation (total ventilation) will be equivalent to 7500ml/min, which is also
represented by VE .
VD: By multiplying 150 ml of dead air volume by the
number of breaths per minute (15 times), dead space
ventilation VD equal to 2250 min/ml is obtained.
VA: By multiplying 350 ml of air that reaches the
alveoli, by the number of breaths per minute (15
times), the alveolar ventilation VA equal to 5250
mi/min is obtained.
Summary: VA= VE - VD (according to the article facing)
Q/V ratio (ventilation to lung perfusion): cardiac output (lung blood flow) is approximately
5000ml/min, so the ratio of alveolar ventilation (VA) to lung perfusion (lung blood flow) is
approximately 1 and the ratio of ventilation to Perfusion is in balance.

Review of lung volumes and capacities in

spirometry
1. Tidal Volume: The volume of air that
enters or leaves the lungs during normal
breathing is called tidal air.
2. Expiratory Reserve Volume (ERV): The
volume of air that leaves the lungs after a
normal exhalation, during a deep
exhalation, is called expiratory reserve
volume.
3. Inspiratory Reserve Volume (IRV): The
volume of air that enters the lungs after a
normal breath, during a deep breath, is
called inspiratory reserve volume.
 4. Total Lung Capacity (TLC): The volume of
air in the lungs after a deep breath will be
equal to the total lung capacity.
5. Forced Vital Capacity (FVC): The volume
of air that is expelled from the lungs after a
deep breath, during a deep exhalation and
by applying force.
6. Residual Volume (RV): The volume of air
that remains in the lungs after deep
exhalation is called residual air.
7. Functional Residual Capacity (FRC): The
volume of air that is left in the lungs after a
normal exhalation is called residual air.
Note: In spirometry, only TV and FVC and the volumes related to these two are used,
and RV, FRC and TLC cannot be calculated.
Margin of the booklet: In obese individuals, the first thing to decrease is ERV.

FRC measurement method:

It was said earlier that RV, FRC and TLC cannot be measured by spirometry, below will be
mentioned the methods by which FRC and therefore TLC can be measured.
1. Helium dilution There is a mixture of helium
gas with a certain volume (V1) and a certain
concentration (C1) in a cylinder. By placing the
cylinder inlet tube in the person's mouth, he is
asked to inhale and exhale. After some time,
helium gas reaches equilibrium between the
cylinder and the person's lungs. At the end of a
normal exhalation, which is FRC, we measure the
concentration of helium gas, which has a
concentration equal to C2 (which is lower than
C1), in both places.

Now using the equation above, FRC (V2) is calculated: C 1 × V 1 = C 2 × (V 1 + V 2 )

C1 × V1 = C2 × (V1 + V2)

Disadvantages of the above method: If a part of the lung is not ventilated due to a complication,
air does not enter those parts and FRC and finally TLC are calculated lower than their normal value.
 2. Body Plethysmography
In this method, Boyle-Marriott's law is used. According
to this law, if the gas temperature is constant, its
volume and pressure will have an inverse relationship,
in other words, at a constant temperature, the product
of pressure and gas volume will be equal to one
constant value. K = P ×V
P ×V=K

The work steps are as follows:

 First, we place the person in a room.
 The person inside the chamber, at the end of a normal exhalation (the volume of air inside the
lungs equal to FRC), does inhalation, which increases the volume of the chest (increases V) and
decreases the pressure inside it (decrease P), according to Boyle-Marriott's law.

 The volume of air inside the chamber, due to the action of the person's breath, is reduced
(decrease in V) and the pressure inside it increases (increase in P.)
 Then, we write Boyle's law once for the person inside the chamber and once for the gas inside
the chamber.
Before the breath After the breath
The room P1 × V1 = P2 × (V1 – ΔV)

Lung disease P3 × FRC = P4 × (FRC+ ΔV)

From the first equation, ΔV is obtained, and by replacing it in the second equation, FRC is
calculated.
Margin of the booklet: Scientifically,
the Body Plethysmography method is
proven as follows:
By drawing a curve on the coordinate axes,
whose horizontal axis is the chamber
pressure and its vertical axis is the mouth
pressure of the person, and calculating the
cotangent of the angle between the curve
and the horizontal axis and some
mathematical calculations, FRC(V) is
obtained.
Margin of the booklet: You can also
calculate the resistance of the airways using
this device (Body Box). In physics, electrical
resistance is obtained by dividing the
electric potential difference (ΔV) by the
current (I). In gases, the pressure difference
causes them to move. Therefore, in the gas
resistance formula, instead of the potential
difference, the pressure difference (ΔP) is
used, and instead of the current, Flow with
the symbol °V is used. Here too, by drawing
a curve on the coordinate axes, which is the
horizontal axis, chamber pressure, and the
flow axis, by calculating the cotangent of
the angle between the curve and the
horizontal axis, the resistance of the
airways is obtained. It is settled here; Because flow depends on time in addition to volume,
and that is why its unit is defined as cubic meters per second.

Calculation of physiological dead air and Bohr's law

If we collect a person's exhaled air (Tidal Volume) in a
container, inside it there is CO2 gas with a specific
concentration of FE, almost all of which originates from the
alveoli, and dead air does not play a role in this CO2
concentration, because dead air is related to The air has very
little CO2.
Therefore, the product of the current volume (VT) in the
exhaled air CO2 concentration (FE) will be equal to the
product of the alveolar volume (VA) in the alveolar CO2
concentration (FA).
VT × FE = VA × FA VT × FE = VA × FA
Of course, the alveolar volume here does not mean the volume of the entire alveoli, because if it
were so, the sum of it with the dead space would not be equal to the flowing air; Rather, its
alveolar volume is the part of it that leaves the lung, that is, it is separate from the remaining
volume.
With a little change and substitution in the face-
to-face equation, we will reach Bohr's equation:
In this equation, 𝑃A𝐶𝑂2 means CO2 pressure of
alveolar air and 𝑃E𝐶𝑂2 means CO2 pressure of
exhaled air, which is also referred to as Tidal End
pressure.
This law is used to calculate the physiological dead air of people and its normal value is 0.3. The
calculation method is as follows:
 First, we take an ABG (Arterial Blood Gas) from the person. One of the values obtained in this
way is arterial CO2 concentration. (𝑃𝑎𝐶𝑂2).
 It should be noted that the arterial CO2 concentration is equal to the alveolar CO2 concentration,
so 𝑃A𝐶𝑂2 = 𝑃𝑎𝐶𝑂2
 Using the capnograph device, you can also calculate 𝑃E𝐶𝑂2.
 By replacing the above values in the Bohr equation, VD can be calculated, which is actually the
physiological dead space.

Calculation of anatomical dead space (the volume of air in the conducting ducts)
The method for calculating anatomical dead space is called Fowler. In this method, N 2 gas
concentration measurement is used.
The procedure is as follows:
 A person inhales pure oxygen without N2.
 The person exhales and gradually the
concentration of N2 increases and finally reaches a
blanket.
 Now we draw a graph on the coordinate axes,
the horizontal axis of which is the exhaled air
volume and the vertical axis of which is the
concentration of N2. According to the opposite
figure, we consider a point where the levels A and
B are equal. The extension of this point on the
horizontal axis (vertical dashed point) indicates the
volume of anatomical dead air.

Important point: Usually, in healthy people, the

volume of anatomical and physiological dead air
is equal, but in many diseases, the volume of
physiological dead air may increase.
Calculation of alveolar ventilation using CO2 pressure
As mentioned before, almost all CO2 in exhaled air originates from the alveoli. Therefore, we can
write:
V°CO2 = V°A × CO2‫غلظت‬
V°CO2 = V°A × CO2 density
By converting concentration to pressure, the opposite equation is obtained, where K is a constant
coefficient:
𝑉°𝐶𝑂 2
V° A = ×K
V°A = (𝑉°𝐶𝑂2/𝑃𝐶𝑂2) × K 𝑃 𝐶𝑂 2

CO2 arterial pressure

To calculate CO2 arterial pressure, with a slight change in the above formula, the opposite formula
emerges:
According to the opposite formula, the arterial pressure of CO2
𝑉°𝐶𝑂 2
depends on the production of CO2 (𝑉°𝐶𝑂2), for this reason, lung 𝑃𝑎 𝐶𝑂 = 0.836 ( )
2 𝑉°𝐴

patients are recommended to consume less carbohydrates,

because for every mole of glucose consumed, 6 moles of oxygen are consumed and 6 moles of CO2

are produced. which causes an increase in CO2 arterial pressure.

Also, arterial CO2 pressure has an inverse relationship with alveolar ventilation, because alveolar
ventilation causes CO2 excretion.
When the body's metabolism increases (exercising), the production of carbon dioxide increases,
so in order to maintain the pressure of carbon dioxide, alveolar ventilation must also increase.
Two conclusions can be drawn:
1) Remaining constant alveolar pressure of oxygen, carbon dioxide, depends on the amount of
ventilation and the speed of the body's metabolism.
2) The higher the amount of ventilation, the higher the alveolar pressure of oxygen and the lower
the alveolar pressure of carbon dioxide, and vice versa.

According to what was said, if the patient presents with 𝑃𝑎𝐶𝑂2 higher than 40mmHg (higher than
normal), there can be two reasons:
1. CO2 production is high (high V°CO2), which is a rare event.
2. Alveolar ventilation is low (low V°A), which is probable.
To check the causes of low alveolar ventilation, we return to the formulas mentioned earlier:
According to the third formula, which was derived from the
previous knowledge, the causes of low alveolar ventilation are V˚ = V˚ - V˚
A E D
the following: 𝑉° 𝐷
V° = V° E
(1 - )
 The minute ventilation is low (V°E), for example, the person
A
𝑉° 𝐸

took superficial breaths and his circulating volume decreased, 𝑉𝐷

or due to the use of opioids and the effect on brain centers, V° = V° E
(1 - )
A
his number of breaths per minute decreased. 𝑉𝑇

 Odd fraction 𝑉𝐷/𝑉𝑇 has increased

Ventilation in different parts of

the lung
Is ventilation the same in different
parts of the lung? no
Inhale Xe133 (radioactive gas) and then
if a person takes a picture of his lungs,
we can see that more ventilation is
done in the lower areas of the lungs. In
general, ventilation decreases from the
base to the top of the lungs, some of it
to The cause is gravity.

Investigating pulmonary diseases and their effect on spirometry

To understand the type of lung disease, it is necessary to first get acquainted with two models of
spirometry charts:
A. FVC and FEV1: As mentioned earlier, FVC is the volume of air that
comes out of the lungs after a deep breath, during a deep exhalation
and by exerting force, and it is usually about 5 liters. To draw a
graph, we draw it based on the volume removed by time. The slope
of this curve (𝛥𝑉/𝛥𝑡) represents flow or the air exit speed.
Another lung volume is (Forced Expiratory Volume in 1 second) FEV1,
which is the volume of air that leaves the person's lungs in the first 1
seconds. This amount is about 4 liters. The ratio of (𝐹𝐸𝑉1/𝐹𝑉𝐶) is
usually around 80% (0.8).
B. Flow-Volume Loop: In this curve, Flow is drawn in terms of
volume. As mentioned, flow means the speed of air exit. (𝛥𝑉/𝛥𝑡)
The upper part of the curve is related to exhalation, at the
beginning of exhalation, the air is expelled at a high speed until
it finally reaches a peak (Flow Expiratory Peak). Then, the air
leaves the lung with a slower speed (a gentler slope).
Margin of the booklet: PEFR (Peak Expiratory Flow Rate): It is the m aximum expiratory
air flow, the lower it is, the greater the obstruction. The normal value of PEFR is
around 500-600 min/L, which reaches 200 L/min in asthma attacks.

The total volume of exhaled air on the horizontal axis represents the FVC (if the air is exhaled
strongly) and on the horizontal axis, according to the volume exhaled in the first second, we also
specify FEV1.
This curve is called Loop because it includes both inhalation and exhalation. To draw this curve, the
person is asked to fill his lungs with air up to the total capacity of the lungs and then quickly take
the air out of the lungs during a deep exhalation.
Now we will examine the types of lung diseases:
• Obstructive Disorders
• Restrictive Disorders
• Mixed Disorders

Obstructive disorders
Among this category of diseases, we can mention asthma, COPD, CF and brosectasis. In the
spirometry of these people, the following are clear:
✓ Peak Expiratory Flow is reduced, that is, the speed of air
leaving the person's lungs is reduced.
✓ Also, the concavity in the upper part of the curve is due to
the non-uniform exit of air from the person's airways.
✓ Usually, 𝐹𝐸𝑉1/𝐹𝑉𝐶 is less than 80%, which is actually due to
the reduction of FEV1.
✓ In these people, the amount of TLC is increased or normal,
which means that the lungs may be full of air due to
obstruction of the airways.
✓ In the spirogram of this disease, the duration of exhalation is
increased and it does not reach the top at all.
✓ The slope of the curve, which was the expression of flow, has
also decreased.
✓ The concavity of the curve increases in this case.

Margin of the booklet: Air trapping is a state in which the RV and FRC values are
increased but the TLC values are not increased by the same amount, this state is seen
in asthma and COPD.
Restrictive Disorders:
In the spirometry of these people, the following are clear:
✓ As can be seen in the figure, the curve is narrowed (like a
hat), which indicates the decrease in the volume of air coming
out of the patient's lung.
✓ Usually the patient's FVC and TLC decrease.
✓ Usually 𝐹𝐸𝑉1/𝐹𝑉𝐶 is normal.
✓ In these patients, the respiratory volume of the lung is
reduced, the causes of which can be pointed out as a decrease
in lung compliance and a disorder in the chest wall (in scoliosis
or muscular dystrophy).
✓ In the spirogram of this disease, the curve reaches the
peak very soon, which cannot be filled more than this due to
the loss of lung elasticity.

Margin of the booklet:

If TLC <180, it is consistent with restrictive dise ase.
If TLC >120, it indicates lung hyperventilation or obstructive disease
Chest diseases such as kyphosis, obesity and ankylosing spondyliti s, diaphragm
paralysis, Guillain Barre syndrome, pleural effusion, myast henia gravis, ALS,
pneumothorax and pleural tumors are all restrictive lung diseases.

DIFUSSION
Diffusion Law: Consider a surface from which
O2 and CO2 are being emitted, in this case, the
amount of gas emission (Vgas) is inversely
related to the thickness of the surface (T) and
to the cross section (A), (the difference in gas
pressure on both sides) The level (P1-P2) and
the diffusion constant (D) have a direct
relationship.
The diffusion constant has a direct relationship
with the degree of gas dissolution (Sol) and an
inverse relationship with the root of the
molecular mass (MW), which is why CO2
passes through the membrane much more
easily.
In the opposite picture, we see a separate unit
of the lung including an alveolus and a
capillary adjacent to it, where a number of red blood cells are passing through this capillary. The
time that red blood cells are available to this alveolus and can react with gases is equal to 0.75
seconds. (The horizontal axis shows the time and the vertical axis shows the relative gas pressure
in the blood plasma).
In this curve, three different gases are compared.
✓ N2O: The concentration of this gas in the blood very quickly reaches its concentration inside
the alveoli. The reason is that this gas is not present in the blood, but it is present in the
alveoli, for this reason it enters the blood quickly, and since it does not enter the red blood
cells and does not react with hemoglobin, its concentration in the blood in a short period of
time It reaches the alveoli. Therefore, the release of N2O depends on the perfusion, and it is
said that this gas is limited perfusion.
✓ CO: This gas is not present in the blood and is quickly transferred from the alveoli to the
blood. But since it has a high affinity with hemoglobin; Its concentration and partial
pressure in blood plasma do not change much. Therefore, the only thing that can stop the
release of CO is the blocking of the release phenomenon, for example, the thickening of the
blood gas barrier.

The affinity of CO is about 240 times higher than O2 to bind to Hb, so all CO binds to
Hb and does not dissolve in plasma, so in cases of CO poisoning, a person may have
normal PaO2, but very low SaO2.

✓ O2: It is between two other gases. Because it reacts with hemoglobin, but its affinity with
hemoglobin is lower than that of CO.

Note: In one third of the time that red blood

cells pass through the vicinity of the alveoli,
that is, in 0.25 seconds, the concentration and
partial pressure of oxygen in the blood plasma
(40 mmHg) reaches the concentration of
oxygen in the alveoli (100 mmHg). The
importance of this matter is that if this
membrane has a problem, more time is
required for the partial pressure of oxygen in
the blood to reach its partial pressure in the
alveoli, and if the damage is more severe, the
partial pressure of oxygen in the blood may
not reach its partial pressure in the alveoli at
all. . (If the membrane has a problem, the
slope of the curve decreases.)
 The effect of exercise: When exercising, the travel time of red
blood cells in the vicinity of the alveoli decreases and reaches
from 0.75 seconds to 0.25 seconds. In this case, if the person is
normal, at this time (0.25 seconds), the oxygen concentration in
the blood reaches the oxygen concentration in the alveoli, but if
the person has abnormal lungs, then the oxygen concentration
in the blood does not reach the appropriate amount. (Exercise
reduces oxygenation time)
Note: sometimes we have a situation where the partial pressure
of oxygen in the alveoli is not 100 mmHg. (Example is 50mmHg)
In this case, the partial pressure of O2 in the blood reaches 0.25
seconds from 40mmHg to 50mmHg.

Lung diffusion capacity for oxygen (DLO2)

It depends on several factors:
Characteristics of the emitting surface (lung): DM
Amount of available blood: VC
Reaction rate of oxygen with hemoglobin: θ

Lung emission capacity for CO (DLCO)

It is difficult to calculate the DL for oxygen, so we
calculate the diffusion capacity for CO gas to obtain the
diffusion properties of the lung. For this, we take a single
breath test from the person. We ask a person to breathe
a mixture of different gases with a certain percentage of
CO. Then we calculate the amount of carbon monoxide
in exhaled air. Now, if we calculate the carbon monoxide
difference between inhaled and exhaled air per unit of
time and pressure, KCO is obtained. which is actually the
diffusion capacity for a functional lung unit.
As mentioned, KCO is the diffusing capacity for a functional lung unit. If we want to obtain the
diffusion capacity of the total lung volume for CO, we must multiply KCO by the lung capacity (VA).
(KCO is used for an alveolar unit and DLCO is used for the whole lung).

The patient inhales a mixture containing 10% CO and immediately we measure the amount of
CO in the blood. If this amount is high, it indicates that the air barrier is healthy because the
complete CO has been rejected. The first change in many diseases is damage to the air barrier,
pay attention that many times the results of spirometry are normal, but the DLCO is abnormal.
Physiological or pathological conditions that affect DLCO and KCO levels:

In people who have kyphoscoliosis and chest deformities or their inspiratory muscles are
weakened, the volume of air that enters the lungs (VA) decreases and according to the
formula that was presented; The amount of DLCO is also reduced. In addition, in these
conditions, DM and then the reaction rate with hemoglobin and available blood also
decrease.
Anemia: In anemia, the available blood volume (VC) and possibly the speed of the reaction
of 1/DL= 1/DM+1/ θ*VC with hemoglobin (h or θ) decreases. As a result, DLCO is also
reduced.

Pulmonary embolism also reduces DLCO with the same mechanism mentioned for anemia.
Valsalva maneuver: In this maneuver, the chest pressure increases, which reduces the
amount of blood inside the chest (vc) and ultimately reduces DLCO.
In a person who has a part of his lung removed, DM and then DLCO decrease.
In emphysema (lung walls are destroyed), pulmonary edema, pulmonary vasculitis and
pulmonary hypertension with different degrees, DM and then DLCO decreases.
In polycythemia, the amount of available blood (VC) increases, which causes DLCO to rise.
Left-to-right shunt and alveolar bleeding increase V and DLCO with the same mechanism of
polycythemia.
DLCO increases in asthma. In asthma, the airways are narrowed and less air enters the
lungs. However, the amount of blood is more than the ducts, which ultimately increases the
DLCO.
There are other factors that increase DLCO by increasing HVC or θ.VC, such as exercise and
supine position.

Explanation of the table: (The

professor only mentioned these
items.)
• In emphysema) due to
alveolar Diffuse destruction,
(PHT) increased pulmonary
blood pressure and KCO anemia
decreases.
• In neuromuscular diseases,
VA and therefore DLCO
decrease. But because the
remaining units have more
absorption, KCO increases.
• In pneumonectomy, part of the units are destroyed, but the remaining units try to
compensate and have a greater diffusion capacity, so KCO increases.
 Explanation of the table:
✓ In a person whose inspiratory
muscles are weakened, VA
decreases and as a result, DLCO
(TLCO) decreases. Although KCO
increases, VA is so low that it
overcomes the increase in KCO
and DLCO decreases.
✓ In a patient who underwent
pneumonectomy, VA decreases
and DLCO decreases while KCO
increases.
✓ In patients with fibrosing
alveolitis, VA decreases and DLCO also decreases, although KCO has not changed much.
✓ In emphysema, KCO decreases, so DLCO also decreases
✓ In pulmonary hypertension (PHT) the volume of air available to VA is high, however, KCO
and DLCO are reduced. (DLCO = KCO × VA)

Blood Flow and Metabolism

As we know, we have two blood circulations in our body.

1. Systemic blood circulation: which starts from the left
ventricle and ends in the right atrium and supplies blood
to the whole body and its pressure is 100 mmHg on
average. ) systolic pressure: 120 mmHg and diastolic
pressure: 80 mmHg)

2. Pulmonary circulation: It starts from the right ventricle and ends at the left atrium, and its
average pressure is 15 mmHg. (systolic pressure: 25mmHg and diastolic pressure: 8mmHg) so the
pressure in the pulmonary blood circulation system is low.

Pulmonary blood flow is divided into two parts;

1. Pulmonary blood flow: which was explained in the pulmonary blood circulation section. The
capacity of this route is about 0.1 of the systemic blood flow and during exercise or any type of
increase in cardiac output, it can receive several times the additional volume without increasing
the blood pressure.
2. Bronchial blood flow: which is arterial blood and originates from the aorta and is responsible
for feeding the lung tissue, after the return blood exchange of this path enters the left atrium
and reduces the content of blood that has entered the left atrium from the lungs and SaO2
reaches about 98% instead of 100% and this state is called physiological shunt.
Pulmonary vessels

Pulmonary vessels are divided into two

categories.
1. Alveolar vessels: they are exposed to
alveolar air and have higher pressure.
2. Extra-alveolar vessels: They are located
outside the alveoli and expand due to the
surrounding connective tissue and usually have
lower pressure. (that is, they have a larger cross-sectional area).

Extraalveolar vessels

Alveolar vessels

Pulmonary Vascular Resistance:

To obtain resistance, we generally divide pressure changes by blood flow.
𝑖𝑛𝑝𝑢𝑡 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒−𝑜𝑢𝑡𝑝𝑢𝑡 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒
For example, we use this relationship 𝑣𝑎𝑠𝑐𝑢𝑙𝑎𝑟 𝑟𝑒𝑠𝑖𝑠𝑡𝑎𝑛𝑐𝑒 = to
blood flow
obtain the resistance of pulmonary blood circulation:

Left arterial pressure − Right arterial pressure

𝑃. 𝑉. 𝑅 =
Blood flow
In the resistance of pulmonary vessels, unlike electrical resistance, we are not dealing with simple
tubes, so the resistance of these vessels is not constant and changes under different conditions. In
these vessels, the more we increase the pressure, the flow increases and the resistance decreases,
which is contrary to our expectations and is caused by two mechanisms:
1. As the pressure increases, the vessels that have been
lying on top of each other open and begin to flow blood
and the resistance decreases (Recruitment).
2. The blood vessels that used to flow the blood are
dilated (Distension).

Lung volume is also effective on resistance. In very low

lung volumes, the extraalveolar vessels are almost on
top of each other, which increases resistance. The more
we increase the volume of the lungs, the more these
vessels open and the resistance decreases. But if the
lung volume exceeds a certain value, the alveolar vessels
overlap and the resistance increases.

Calculation of Pulmonary Blood Flow

Fick's Law: Using this law, we can calculate the amount
of oxygen consumed. It is also possible to calculate
cardiac output in this law.
o Vo2: amount of oxygen consumed
o Q: Cardiac output
o Cao2: oxygen content of arterial blood
o Cvo2: oxygen content of venous blood
 Blood flow in different parts of the lung
Based on this, we divide the lung into three areas.
1. Zone 1: It is located at the top of the lung. In this area, the
alveolar pressure (PA) is higher than the arterial pressure (Pa)
and overcomes it. Therefore, the vessels lie on top of each
other and the blood flow in the peak of the lung is less than
in other areas.
2. Zone 2: It is located in the middle of the lung. In this area,
arterial pressure is higher than alveolar pressure and alveolar
pressure is higher than venous pressure. No matter how far
we are from these vessels, eventually the alveolar pressure
will prevail and the vessels will lie on top of each other.

3. Zone 3: At the base of the lung, the arterial pressure is higher than the venous pressure and the
venous pressure is higher than the alveolar pressure. As a result, the vessels are always closed and
the amount of blood flow in the base is higher.

There is an important point about pulmonary blood

flow: the more O2 increases, the flow increases. The
reverse of this story is also true. That is, in places of
the lung where oxygen is less, the blood flow
decreases due to the vasoconstriction of the vessels)
the reason is to keep the ratio of ventilation to
perfusion constant.

From the apex of the lung towards the base of the lung due to the effect of gravity in
standing conditions, the pulmonary artery pressure (Pa) and alveolar vein pressure (Pv)
increase, but the intra-alveolar pressure PA remains constant. Therefore, the lung is divided
into three zones in terms of these three pressures. they do.
In normal conditions, Zone 2 has a very small area because in most parts of the lung, the
alveolar pressure is lower than the venous pressure.
In most cases and under normal conditions, most of the lung is located in Zone 3, and most
of the blood supply to the lung reaches the base of the lungs.
The increase in blood flow from the apex to the base of the lungs, or Q, in normal conditions
is greater than the increase in ventilation, which means that the amount of blood in the base
of the lungs is greater than the amount of air, and this creates a V/Q mismatch. But due to
the large extent of alveolar ventilation, it has no effect on the transfer of respiratory gases.
An important point about cardiopulmonary
edema: Consider a capillary whose
hydrostatic pressure has increased and fluid
is oozing from it. This fluid reaches the
interstitium first. Therefore, in the initial
stages of cardiopulmonary edema, this
space is full of fluid. But finally, a lot of this
liquid enters the alveolar space and causes
significant edema.

Metabolism in the respiratory system

In the pulmonary circulation, there are a series of substances, including angiotensin 1, which is
converted to angiotensin 2 by angiotensin-converting enzyme. In addition, in this system,
arachidonic acid is produced from phospholipids under the influence of phospholipase A 2, which
causes the production of different substances, including prostaglandins, thromboxane A 2, and
leukotrienes.
The lungs are a suitable place for the metabolism of various substances.