EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY

CHAPTER 9: THE RESPIRATORY SYSTEM

REVIEWER – Neonatal and Pediatric
PRIMARY FUNCTION of the Respiratory
System: Gas exchange and continuous
absorption of oxygen and elimination of carbon
dioxide
• External respiration- exchange
between alveolar gas and blood
• Internal respiration- exchange of gas
between blood and tissues at the
cellular level
Close “match” of gas and blood across a large
but extremely thin blood-gas barrier membrane
enables efficient gas exchange to occur via
simple diffusion
• Approximately 250 million liters of
each are moved and matched during
an average 75-year life span.
• Respiratory system is regulated by the
nervous system: It is capable of
increasing function in response to
elevated demands brought on by
stressful conditions such as exercise
and disease
DEVELOPMENT OF THE RESPIRATORY SYSTEM
• Developmental phases of a fertilized
egg are divided into the embryonic
and fetal periods.
❖ EMBRYONIC - first 8 weeks
of pregnancy; Major organs
will develop
❖ FETAL - remaining 32 weeks
of pregnancy; organs continue
to develop and refine their
structure and function
THREE DISTINCT GERMINAL TISSUE
LAYERS: endoderm, mesoderm, and
ectoderm
• Respiratory development BEGINS in
EMBRONIC PERIOD: approximately
day 22 after fertilization
❖ primitive laryngotracheal tube
forms from a groove in the
fourth pharyngeal pouch
❖ From that groove a tracheal
bud forms by the end of the
fourth week of life
❖ WEEK 5: tracheal bud
continues to develop and
bifurcates into left and right
primary bronchial buds
• Approximately 6 WEEKS: lung and
airway growth has the appearance of a
glandular structure (6 to 16 weeks)
PSEUDOGLANDULAR STAGE
❖ NEXT 10 WEEKS: growth and
branching of the
tracheobronchial tree and
pulmonary vasculature
continue and culminate with
formation of the terminal
and respiratory bronchioles.
▪ TERMINAL
BRONCHIOLES:
conducting airways only
and do not participate in
gas exchange with blood
▪ RESPIRATORY
BRONCHIOLES: more
superficial capillaries
and are capable of gas
exchange with blood,
becoming more
elaborate as
development continues
❖ Epithelial lining (airways)
▪ Columnar epithelia-
proximal airways
▪ Cuboidal epithelia-
more distal bronchioles
• WEEK 16-26:
CANALICULAR STAGE
❖ overlaps with the
Pseudoglandular stage because
the superior regions are
developing slightly faster than the
inferior regions
❖ PRIMARY CHANGES…………...
Development of two to four more
generations of respiratory
bronchioles from each terminal
bronchiole.
❖ Last several weeks: region
beyond each terminal bronchiole
forms the functional structure –
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric

• 32nd- 40th WEEK- ALVEOLAR STAGE

❖ ACINUS- Basic gas-exchange
unit of the lung ❖ development of mature
❖ Two principal epithelial cell types alveoli, accompanied by
-cover the gas-exchange surface capillary proliferation within
(begin to appear) the walls
▪ Type I Pneumocyte- ❖ FINAL PHASE OF LUNG
FLATTER squamous DEVELOPMENT
epithelial cells ❖ terminal saccules develop
▪ Type II Pneumocyte -
hexagonal pouchlike region –
ROUNDED secretory
ALVEOLI
cells
❖ At the end of the canalicular
period (24 to 26 weeks of
gestation), the fetus, if born, is
capable of sufficient gas
exchange and viable if supported
with supplemental O2, ventilatory
support, and surfactant
administration
❖ FULL TERM NEW BORN
• 26 weeks to birth - TERMINAL
INFANT: 50 MILLION
SACCULAR STAGE
❖ more terminal bronchioles and their alveoli, this number
associated acini form and develop continues to increase for
❖ COMPLETE formation of the total approximately 2 to 3 years
number of terminal bronchioles after birth
❖ Differentiate Type I and II ❖ PRODUCED AROUND 24
Pneumocytes TO 25 WEEKS of
❖ Capillaries continue to form near and development by type II
bulge from the surface of the acinus pneumocytes --
Pulmonary Surfactant-
promotes lung inflation
and protects the alveolar
surface
❖ PS: phospholipids, small
amount of protein (types SP-
A, SP-B, and SP-C), and a
trace of carbohydrates
❖ Phospholipid
components:
o phosphatidylcholine
(lecithin [L] and
sphingomyelin [S])
o phosphatidylglycerol
(PG).
❖ Type I Pneumocytes – ❖ The amount of these
thin and elongate to cover phospholipids (the L/S
saccule walls -- primary gas- ratio and PG
exchange cells in lung with concentration) provides a
close approximation to predictive index of the
developing pulmonary lung maturity in a fetus
capillaries before birth and the risks
❖ Type II Pneumocytes- for the development of
form and secrete the vital
respiratory distress
pulmonary surfactants that
are necessary to alter ❖ L/S Ratio:
surface tension and help o ≥2 - Relatively LOW
keep the lungs inflated risk
o <1.5 – HIGH Risk
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric

• Surfactant synthesis: regulated by

hormones, genes and factors including TRANSITION FROM UTERINE TO
GLUCOCORTICOIDS EXTRAUTERINE LIFE
• GLUCOCORTICOSTEROID
PRODUCTION- increases at the end of PLACENTAL STRUCTURE AND FUNCTION
gestation and stimulates receptors in type • PLACENTA- provide fetus effective
II pneumocytes, increasing surfactant circulatory interface with the circulation of
production and improving the L/S ratio. the mother
• DISTINCTIVE function of the • 1 WEEK (Uterine Implantation)
developing lung: formation of relatively ❖ Chorionic villi- vascular
large amounts of fetal lung fluid that passes projections that arise from
into amniotic fluid. chorion of embryo ► penetrate
• Fetal lung fluid: plasma ultrafiltrate from fetal the uterine endometrium
pulmonary microcirculation + components of ❖ Gestation proceeds > villi
pulmonary surfactant + other fluids from pulmonary increase in number and
epithelial cells
complexity > erode the
• CONSTANTLY PRODUCED AND
endometrium > create regular
REPLACE – keeping fetal lung inflated at
pockets (INTERVILLOUS
slight positive pressure with respect to
SPACES) --- filled with maternal
amniotic fluid pressure
blood
• IMPORTANT in stimulating normal lung
▪ Maternal blood in
development
intervillous spaces
• At term- fetal lung filled with bathes embryonic villi
approximately 40 mL of fluid creating oxygen-rich
• incomplete inflation and poorly and nutrient-rich
developed (hypoplastic) lungs ► environment
inadequate fetal breathing and low • Maternal blood flows into the intervillous space
amounts of amniotic fluid formation through the spiral arteries, whereas fetal blood
(oligohydramnios) is supplied to the villi from two umbilical
• MID GESTATION: fetus begins to make arteries.
respiratory efforts with little to no fluid in • Maternal and fetal blood come into close
and out of the lungs proximity but remain separated by an
• RHYTHM AND DEPTH: Periodic and embryonic membrane
Irregular (reflecting the development of • Oxygenated fetal blood – LEAVES
respiratory centers in the brain and chorionic villi capillaries through placental
respiratory muscles) venules >> RETURNS to the fetus through
• At birth SINGLE UMBILICAL VEIN
❖ Lungs of MALE infant: larger +
have greater number of
respiratory bronchioles
❖ Evaluating breathing efforts and
surfactant production: 26-36
WEEKS of gestation – FEMALE
have better developed lung
function + slightly less susceptible
to RDS
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric
• STUNT intrauterine growth – abnormal
implantation of the placenta, tearing of
the placenta from the uterine wall, or
decreased placental blood flow ► fetal
asphyxia, increase risk for brain
damage, respiratory distress in
immediate post-natal period
\
FETAL CIRCULATION
• Assessment of umbilical vein blood
gas data (cord blood gas) shortly after
birth is a method of determining the
degree of fetal asphyxiation during the
birth process
• O2 content and delivery by fetal blood
are almost the same as adult blood
despite the much lower PO2
❖ FACTORS: in fetal blood
1. Relatively higher
content of hemoglobin
(18 g/dL)
2. Hematocrit (54%)
3. Presence of fetal
hemoglobin
✓ increased affinity
for O2 and a more
pronounced Bohr
effect (reduced
oxyhemoglobin
affinity with
acidosis) to
enhance O2
release
• P50 (PO2 that saturates 50% of
the hemoglobin) -- 6 to 8 mm
Hg less than the P50 for adult
hemoglobin (HbA) -- indicates
the degree of the shift toward
higher affinity
• AT BIRTH - 70% of circulating
hemoglobin is HbF
• HbA gradually replaces HbF
during the first 6 months of
extrauterine life ► HbA genes in
bone marrow switch on and
HbF genes in the liver (major
site of fetal erythrocyte
development) are switched off
• Three important BYPASS pathways
(shunts)
• ductus venosus, ductus
arteriosus, and foramen ovale
• Approximately ONE-THIRD of
OXYGENATED blood flows to the lower
trunk and extremities
• other TWO-THIRDS flows through the
ductus venosus, bypassing the liver’s
circulation, and flows to the inferior vena
cava
• This BETTER OXYGENATED BLOOD in
the inferior vena cava mixes with the
venous blood returning from the lower
trunk and extremities entering the right
atrium
• APPROXIMATELY 50% -- (of this blood)
is shunted from the right atrium into the
left atrium through an opening in the
interatrial septum called the foramen
ovale
• Left atrial blood flows to the left ventricle
and then to the ascending aorta, where it
continues on to the brain, brachiocephalic
trunk, and descending aorta.
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric
• VENOUS BLOOD from the Superior Vena
Cava is directed downward through the
right atrium into the right ventricle and then
into the main pulmonary artery
• DUCTUS ARTERIOSUS (a muscular
vessel attached to the trunk of the
pulmonary artery and the aorta) – DILATE
+ Pulmonary Arteries CONSTRICT ------
due to relatively low PO2 and various
prostaglandins in fetal blood
• Leads to INCREASE IN PULMONARY
VASCULAR RESISTANCE = pulmonary
artery pressure higher than aortic blood
pressure
• RESULT – 90% of blood flow entering the
pulmonary artery takes the path of least
resistance by shunting through the ductus
arteriosus to aorta
• ONLY 10% - flows into the LUNGS
• Blood from Ductus Arteriosus + Blood from
aorta → systemic circulation (Some of this
blood flows to the gut, lower extremities, and
placenta)
• TWO UMBILICAL ARTERIES – Carry blood
from fetal aorta to the placenta (carrying out
fetal-maternal gas and nutrient exchange)
• Days before birth, the epithelia of the lung
stop the production of lung fluid –
absorbed back into the fetal circulation
• Normal Vaginal Delivery
o 1/3 is cleared through the
compression of the thorax
o 2/3 cleared through pulmonary
capillaries and lymphatics
• Must develop very high transpulmonary
pressure -- overcome opposing forces of
fluid viscosity in the airways and surface
tension of the alveoli
• Stimuli via peripheral and central
chemoreceptors augmented by skin
receptors
• FIRST BREATH – new tactile and thermal
stimuli
• First, no air enters newborn lung until
transpulmonary pressure exceeds 40
cmH20
• As volume increases, amount of pressure
decreases
• As lung filled with air – results in
pulmonary vasodilation
o pH increases
o PO2 increases
o PCO2 decreases
Result:
♣ Pulmonary Vasodilation
♣ Lower pulmonary vascular resistance
♣ Constriction of the Ductus Arteriosus
Greater blood flow through pulmonary
circulation
• Maternal loss of prostaglandin – closure of
ductus arteriosus
• Alveolar air content + constriction =
promotes matching of ventilation and blood
flow
• Clamping of umbilical cord – cessation of
umbilical and placental blood flow =
closure of ductus venosus and increase
Systemic vascular resistance
• ↑ Systemic Vascular Resistance = ↑ left
sided heart pressure = ↑ Left atrial
pressure = Closes Foramen ovale
• Anatomic closure of the ductus normally
occurs within 3 weeks of birth.
Permanent closure of the tissue flap
covering the foramen ovale may take
several months
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric
POSTNATAL LUNG DEVELOPMENT
UPPER AIRWAY
• Increase likelihood of airway obstruction
o Greater relative weight of head –
acute flexion of cervical spine –
infant neck flexion
o Smaller nasal passages than
adult
o Jaw – rounder
o Tongue – much larger relative to
size of oral cavity
• Most infants prefer to breathe through
nose
• Shift to oral breathing through nasal
occlusion and hypoxia
• 4 to 5 months of age – full oral ventilation
• Larynx – higher in the neck – GLOTTIS
located between C3 and C4, more funnel
shaped
o Swallowing - larynx provides a
direct connection to
nasopharynx- Allow breathe and
suckle at the same time
• Narrowest region of upper airway –
cricoid cartilage
o Glottis in adult
• Epiglottis – longer and less flexible, lies
higher and more horizontal
• Anatomic descent of the epiglottis begins
at 2 1/2 to 3 months of age.
• Large conducting airways – shorter and
narrower
• Trachea
o normal newborn
▪ 5-6 cm long & 4mm
diameter
o Small preterm
▪ 2 cm long & 2-3 mm
diameter
• Anatomic deadspace is smaller at
approx. 1.5 ml/kg of bodyweight
• Mainstem bronchi – branch off from
trachea at less acute angle
o Right mainstem bronchus is more
align with trachea
• Mean airway diameter – main bronchi to
respiratory bronchioles -- ↑ 2x – 3x
• Smooth muscle (airways to respiratory
bronchioles) increases until 8 months
• Distinct C-shaped rings of cartilage are
found in the trachea and main stem
bronchi of the neonate
LOWER AIRWAY AND ALVEOLI
• 480 million alveoli
• All development is generally complete by
10 years of age – most occurring at 1 ½
post-natal year
• Adulthood – ACM gas exchange surface
area 140m2
• Gene and mechanical stretch → STEM
CELL ACTIVATION IN THE LUNGS –
responsible for alveolar development in
the
adulthood after loss of lung tissue
DEVELOPMENT OF THE VASCULAR,
LYMPHATIC, AND NERVOUS SYSTEM
• The respiratory system is a unique organ
in that it receives a double blood supply:
o one from the left ventricle and
o one from the right ventricle
• right heart – bulk of flow to pulmonary
circulation
• left heart – smaller amount of flow (1% -
2%)
• Bronchial arteries – supply O2 to the
airway tissue, blood vessels, nerves,
lymphatics, and visceral pleura
• The lung’s double circulation benefits
the entire lung in health and helps
compensate for deficiencies or disease
processes that can affect either circulation.
EGAN’S FUNDAMENTALS OF RESPIRATORY THERAPY
CHAPTER 9: THE RESPIRATORY SYSTEM
REVIEWER – Neonatal and Pediatric
• Lymphatic vessels – central role in the
control of fluid and protein balance
within the lung and house various
defensive cells
• Fluid collected from the pleural space and
interstitium is carried by the pleural
capillaries and vessels through the
lymphatic system back to the root of the
lung (hilum), where numerous lymph
nodes are located
• Neuronal centers in brainstem – medulla
oblongata and pons
o Automatic control of breathing
• Phrenic and intercostal nerves – primary
component of somatic (motor) nervous
system that carry nervous signals from
brainstem to respiratory muscles
o Diaphragm – phrenic nerves
o Intercostal muscles – intercostal
nerves
o responsible for enlarging the
thorax (inspiration) and allow
exhalation by relaxing, letting the
thorax and lungs recoil back to
their preinspiratory position
• Sympathetic and Parasympathetic –
visceral control of the smooth muscle of
respiratory system
o Sympathetic
▪ Bronchodilation of
bronchioles
▪ Vasoconstriction of
blood vessels
o Parasympathetic
▪ Mucus glands to
produce mucus
• Cranial Nerve X (Vagus Nerve) – carries
motor and sensory signals of
parasympathetic system
• Branches from each thoracic spinal
nerve carry sympathetic motor and
sensory signals to and from the lungs

CHEST WALL DEVELOPMENT, DIAPHRAGM,

AND LUNG VOLUME
• Infant thoracic cage – more box-like with
ribs being horizontally oriented or elevated
• Ossification of the ribs and sternum
normally complete by 25 years of age
• Grunting – “laryngeal braking”
o Narrowing of glottis or larynx
during exhalation
o Infants in respiratory distress
grunt, a manifestation of laryngeal
braking