Review of Respiratory

Physiology
Steady State
Lung O
2
Uptake rate
= Cell O
2
Utilization rate

Cell CO
2
Production rate
= Lung CO
2
Release rate
Gaseous Environment.
Atmosphere: Nitrogen and Oxygen,
negligible Carbon Dioxide.



Clinical Relevance of Environment
Altitude: PO
2
depends on P
B

Suffocation: PO
2
depends on fractional O
2

Oxygen therapy: PO
2
depends on fractional O
2
P F P
I I B
O O
2 2
47 = - ( )
Diffusion and Diffusion
Abnormality
Ficks Law for Diffusion for Gases
O
2

CO
2

T
P
1

P
2

A

( ) V
A D
T
P P
gas
=


1 2
Single Breath D
L
CO
Single inspiration of a dilute CO
mixture
10 second breath-hold
Measure CO uptake using infrared
detector to compare inspiratory and
expiratory concentrations
Normal Value: 25 ml/min/mmHg
Clinical Interpretation of D
L
CO.
Decreases with loss of surface area.
Decreases with increasing membrane
thickness

Decreases with ventilation/perfusion
mismatching
Summary: D
L
CO better index of overall
lung function than diffusion capabilities
per se.
Two Factors Affect Gas Transfer
Rate
Diffusion rate of a gas
Perfusion Rate (Pulmonary blood
flow)
Gases must be carried away to maintain
local diffusion gradients in the lung.
O
2
Diffusion during Normoxia
Lung Mechanics in Obstructive
and Restrictive Disease
Measuring vital capacity and its
subcomponents.
Use a spirometer.
TLC
RV
VC
TV
FRC
IC
IRV
ERV
RV
Can Use
Spiromenter
Cant Use a Spirometer
Measuring Residual Volume
Cant use a Spirometer
Use instead:
Nitrogen Washout
Helium Dilution Method
Plethysmograph
Obstructive Disease
Difficult to get air out of the lungs
Obstruct expiration

Examples:
emphysema
chronic bronchitis
asthma.
Restrictive Disease
Difficult to get air in to the lungs
Restrict inspiration
Examples:
intersitial fibrosis
sarcoidosis
muscular diseases
chestwall deformities.
Lung Capacity and Disease
Summary
Obstructive Disease:
Decreased VC
Increased TLC, RV, FRC.
Restrictive Disease:
Decreased VC
Decreased TLC, RV, FRC.
Fig 5: Lung Capacity and
Disease
Normal
RV
ERV
TV
IRV
FRC
VC
Restrictive
RV
ERV
TV
IRV
FRC
VC
Obstructive
RV
ERV
TV
IRV
FRC
VC
125
100
75
50
25
0
%

N
o
r
m
a
l

T
L
C

Forced Vital Capacity
FEV
1.0
/ FVC Ratio
Small Airways Disease
FEF
25-75

Flow -Volume Curves
Peak Flow
Pulmonary Function Summary
Obstructive
Disease
Restrictive
Disease
FEV
1.0
Decreased Decreased
FVC Decreased Decreased
FEV
1.0
/FVC Decreased Unchanged or
Increased
Peak Flow Decreased Decreased or
Unchanged
RV/TLC Increased Unchanged


CLINICAL USE OF IDEAL
ALVEOLAR GAS VALUES
Ideal Alveolar Gas Equation.
P P
P
R
P F
R
R
A I
A
A I
O O
CO
CO O
2 2
2
2 2
1
= +

|
\

|
.
|
Clinically Useful Form:
Complete Form:
P P
P
R
A I
A
O O
CO
2 2
2
=
USE #1
Compare P
A
O
2
to P
a
O
2
Healthy people: P
A
O
2
= P
a
O
2

Two Approaches to Comparison
(P
A
O
2
- P
a
O
2
) difference
P
a
O
2
/ P
A
O
2
ratio
A-a Difference
P
A
O
2
- P
a
O
2

Normally 5-20 mmHg
Because of normal anatomical shunt
Ventilation/Perfusion mismatching.
A-a difference increases with
pulmonary disease.
Problem: Normal range changes on
100% O
2
.
a/A ratio
Normally averages just over 0.8 (Am.
Rev. Resp. Dis. 109: 142-145, 1974).
a/A ratio falls with pulmonary
disease.
Lower limit normal:
young (room air) : 0.74
older (room air) : 0.78
Both groups (100% O
2
): 0.82
(A-a) Difference vs. a/A Ratio
Normal
Normal
(
A
-
a
)

P
O
2

D
i
f
f
e
r
e
n
c
e

(
m
m
H
g
)

a
/
A


P
O
2


r
a
t
i
o

Sick
Sick
Use #2
P
A
O
2
Estimates P
c
O
2


Useful for calculation of Venous
Admixture or Shunt
Venous Admixture

'
'
Q
Q
C C
C C
S
T
c a
c v
O O
O O
=

2 2
2 2
Q
T
C
a
O
2
(Q
T
- Q
s
) C
c
O
2
Q
s
C
v
O
2
P
A
O
2
Diagnosis of True Shunt
Breathing 100% oxygen -
will not abolish hypoxemia due to
shunt
REASON: shunted blood never
exposed to the high alveolar PO
2
.
Blood Gases
Oxygen Blood Gas Quantities
Partial Pressure
Saturation
Content

Carrying Capacity: O
2
content at
100% saturation.
Significance of Sigmoid Curve
4 Point Curve
Critical PO
2
V
Defining Content and Capacity
C Hb
S
O
O
2
2
136
100%
= - - . [ ]
%
Blood
Hemoglobin --> Allows Blood to hold
more oxygen.
P
50
: Reciprical to Hb-O
2
Affinity
(H
+
, CO
2
, Temp, & 2,3-DPG)
Capacity: Anemia, Polycythemia
Hematocrit
Hemoglobin
Hemoglobin variants exist (e.g. Hb
f
)
Four (+one) Things Change
Oxyhemoglobin Affinity
Hydrogen Ion Concentration, [H
+
]
Carbon Dioxide Partial Pressure, PCO
2
Temperature
[2,3-DPG]






Special Case: Carbon Monoxide
Three Things That Change O
2

Carrying Capacity
Changes in Hb Concentration
Presence of Carbon Monoxide
Formation of Methemoglobin
Minute Ventilation
Flow (vol/time) moved into or out of
the lungs.
Measured by collecting expired
volume for a fixed time.
Normal value is 7.5 L/min (BTPS).

V V f
E T
=
Partitioning Minute Ventilation.
Alveolar Ventilation: the volume per
min entering gas exchange surfaces.
Dead space Ventilation: the volume
per min that is wasted

( ) V V V V V f V f V f
A E d T d T d
= = =
Alveolar Ventilation Equation.
(Rearranged)
P
V (STPD)
863 mmHg
A
CO
CO
2
2
=

( ) V BTPS
A
Defining Adequate Ventilation
Normal--> P
a
CO
2
= 40 mmHg

Hypoventilation --> High P
a
CO
2

Hyperventilation --> Low P
a
CO
2
Respiratory Acid-Base
Henderson-Hasselbach Equation:



Changes in PCO
2
cause changes in [H
+
] by
mass action.
Increased PCO
2
resp. acidosis
Decreased PCO
2
resp. alkalosis.
CO H O H CO H HCO
2 2 2 3 3
+ +
+ Carbonic Anhydrase
pH
HCO
P
CO
= +

6 1
0 03
3
2
. log
[ ]
( . )
CAUSES OF HYPOXEMIA
Low F
I
O
2

Hypoventilation
True shunt
Diffusion Abnormality
Ventilation / Perfusion Mismatching


Hypoxemia Analysis
Step 1
Is P
A
CO
2
> 40 mmHg
AND
a/A > 0.74 or (A-a) < 20 mmHg
Pure
Hypoventilation
yes
Choose between:
Shunt
Diffusion Abnormality
V/Q Mismatching
No
Continue
Hypoxemia Analysis
Step 2
Can
Hypoxemia be eliminated
by 100% O
2
True
Shunt
No
Choose between:
Diffusion Abnormality
V/Q Mismatching
Yes
Continue
Hypoxemia Analysis
Step 3
Is the D
L
CO
Normal
?
Diffusion Normal
must be
V/Q Mismatching
yes
No
Cant choose between:
Diffusion Abnormality
V/Q Mismatching
or Combination
Questions?