2 Mechanics

of Breathing

OBJECTIVES
The reader understands the mechanical properties of the lung and the chest wall during breathing.
Describes the generation of a pressure gradient between the atmosphere and the alveoli.
Describes the passive expansion and recoil of the alveoli.
Defines the mechanical interaction of the lung and the chest wall, and relates this concept to the
negative intrapleural pressure.
Describes the pressure-volume characteristics of the lung and the chest wall, and predicts
changes in the compliance of the lung and the chest wall in different physiologic and pathologic
conditions.
States the roles of pulmonary surfactant and alveolar interdependence in the recoil and
expansion of the lung.
Defines the functional residual capacity (FRC), and uses his or her understanding of lung-chest
wall interactions to predict changes in FRC in different physiologic and pathologic conditions.
Defines airways resistance and lists the factors that contribute to or alter the resistance to
airflow.
Describes the dynamic compression of airways during a forced expiration.
Relates changes in the dynamic compliance of the lung to alterations in airways resistance.
Lists the factors that contribute to the work of breathing.
Predicts alterations in the work of breathing in different physiologic and pathologic states.

Air, like other fluids, moves from a region of higher pressure to one of lower pressure. Therefore,
for air to be moved into or out of the lungs, a pressure difference between the atmosphere and the alveoli
must be established. If there is no pressure difference, no airflow will occur.
Under normal circumstances, inspiration is accomplished by causing alveolar pressure to fall below
atmospheric pressure. When the mechanics of breathing are being discussed, atmospheric pressure is
conventionally referred to as 0 cm H2O, so lowering alveolar pressure below atmospheric pressure is
known as negative-pressure breathing. As soon as a pressure difference sufficient to overcome the
resistance to airflow offered by the conducting airways is established between the atmosphere and the
alveoli, air flows into the lungs. It is also possible to cause air to flow into the lungs by raising the
pressure at the nose and mouth above alveolar pressure. This positive-pressure ventilation is generally
used on patients unable to generate a sufficient pressure difference between the atmosphere and the
alveoli by normal negative-pressure breathing. Air flows out of the lungs when alveolar pressure is
sufficiently greater than atmospheric pressure to overcome the resistance to airflow offered by the
conducting airways.
GENERATION OF A PRESSURE DIFFERENCE BETWEEN ATMOSPHERE
AND ALVEOLI
During normal negative-pressure breathing, alveolar pressure is made lower than atmospheric pressure.
This is accomplished by causing the muscles of inspiration to contract, which increases the volume of the
alveoli, thus lowering the alveolar pressure according to Boyle law. (See Appendix II: The Laws
Governing the Behavior of Gases.)

Passive Expansion of Alveoli

The alveoli are not capable of expanding themselves. They only expand passively in response to an
increased distending pressure across the alveolar wall. This increased transmural pressure
difference, generated by the muscles of inspiration, further opens the highly distensible alveoli, and thus
lowers the alveolar pressure. The transmural pressure difference is conventionally calculated by
subtracting the outside pressure (in this case, the intrapleural pressure) from the inside pressure (in this
case, the alveolar pressure).

Negative Intrapleural Pressure

The pressure in the thin space between the visceral and parietal pleura is normally slightly
subatmospheric, even when no inspiratory muscles are contracting. This negative intrapleural pressure
(sometimes also referred to as negative intrathoracic pressure) of –3 to –5 cm H2O is mainly caused by
the mechanical interaction between the lung and the chest wall. At the end of expiration, when all the
respiratory muscles are relaxed, the lung and the chest wall are acting on each other in opposite
directions. The lung is tending to decrease its volume because of the inward elastic recoil of the
distended alveolar walls; the chest wall is tending to increase its volume because of its outward elastic
recoil. Thus, the chest wall is acting to hold the alveoli open in opposition to their elastic recoil.
Similarly, the lung is acting by its elastic recoil to hold the chest wall in. Because of this
interaction, the pressure is negative at the surface of the very thin (about 10–30 μm in thickness at normal
lung volumes), fluid-filled pleural space, as seen on the left in Figure 2–1. There is normally no gas in the
intrapleural space, and the lung is held against the chest wall by the thin layer of serous intrapleural
liquid, estimated to have a total volume of about 15 to 25 mL in an average adult.
Figure 2–1. Representation of the interaction of the lung and chest wall. Left: At end expiration, the
muscles of respiration are relaxed. The inward elastic recoil of the lung is balanced by the outward
elastic recoil of the chest wall. Intrapleural pressure is-5 cm H2O; alveolar pressure is 0. The
transmural pressure difference across the alveolus is therefore 0 cm H2O–(–5 cm H2O), or 5 cm
H2O. Since alveolar pressure is equal to atmospheric pressure, no airflow occurs. Right: During
inspiration, contraction of the muscles of inspiration causes intrapleural pressure to become more
negative. The transmural pressure difference increases and the alveoli are distended, decreasing
alveolar pressure below atmospheric pressure, which causes air to flow into the alveoli.

Initially, before any airflow occurs, the pressure inside the alveoli is the same as atmospheric
pressure—by convention 0 cm H2O. Alveolar pressure is greater than intrapleural pressure because it
represents the sum of the intrapleural pressure plus the alveolar elastic recoil pressure:

Alveolar pressure = intrapleural pressure + alveolar elastic recoil pressure

The muscles of inspiration act to increase the volume of the thoracic cavity. The outside of the lung
(the visceral pleura) adheres to the inside of the chest wall (the parietal pleura). As the inspiratory
muscles contract, expanding the thoracic volume and increasing the outward stress on the lung, the
intrapleural pressure becomes more negative. Therefore, the transmural pressure difference tending to
distend the alveolar wall (sometimes called the transpulmonary pressure) increases as shown in Figure
2–1, and the alveoli enlarge passively. Increasing alveolar volume lowers alveolar pressure and
establishes the pressure gradient for airflow into the lung. In reality, only a small percentage of the total
number of alveoli are directly exposed to the intrapleural surface pressure, and at first thought, it is
difficult to see how alveoli located centrally in the lung could be expanded by a more negative
intrapleural pressure. However, analysis has shown that the pressure at the pleural surface is
transmitted through the alveolar walls to more centrally located alveoli and small airways. This
structural interdependence of alveolar units is depicted in Figure 2–2.
Figure 2–2. Structural interdependence of alveolar units. The pressure difference across the
outermost alveoli is transmitted mechanically through the lung via the alveolar septa. The insets
show the author’s idea of what might happen in negative-pressure breathing and positive-pressure
ventilation. In negative-pressure breathing (Inset A) the mechanical stress would likely be
transmitted from the more exterior alveoli (those closest to the chest wall) to more interior alveoli,
so the exterior alveoli might be more distended. In positive-pressure ventilation (Inset B) the lungs
must push against the diaphragm and rib cage to move them. The outermost alveoli might be more
compressed than those located more interiorly.

Note that in Figure 2–1, the inward alveolar elastic recoil calculated by the equation above is equal to
the transmural pressure difference. This is true under static conditions, but they may differ slightly during
a breath as the alveoli are stretched.

The Muscles of Respiration

INSPIRATORY MUSCLES
The muscles of inspiration include the diaphragm, the external intercostals, and the accessory muscles of
inspiration, which include the sternocleidomastoid, the trapezius, and the muscles of the vertebral column.
The Diaphragm—The diaphragm is a large (about 250 cm2 in surface area) dome-shaped muscle that
separates the thorax from the abdominal cavity. As mentioned in Chapter 1, the diaphragm is considered
to be an integral part of the chest wall and must always be considered in the analysis of chest wall
mechanics.
The diaphragm is the primary muscle of inspiration. When a person is in the supine position, the
diaphragm is responsible for about two thirds of the air that enters the lungs during normal quiet breathing