Breathing & Circulation

Ns. Farida Juanita, S.Kep.,M.Kep.

 Introduction to Pulmonary
Physiology
• The pulmonary system, in tandem with
the cardiovascular system, works to
carry out three functions:
– Ventilation
– Perfusion
– Diffusion
 Ventilation
• Definition: movement of
air from the external
environment to the
alveoli
• Components:
– Brain
– Innervation
– Chest wall
– Upper airways
– Lower airways
 The Brain’s Role in Ventilation
• Ventilation is
primarily controlled
by the pH of the
cerebrospinal fluid
• The brainstem
actually floats in CSF
• So, the brainstem
plays a primary role
in initiating
ventilation
 Control of Ventilation
Chemical Mechanical
• Primary: pH of CSF, • Stretch receptors in
directly related to the the lung itself
arterial level of CO2 (Herring-Breur
(PaCO2).
receptors) prevent the
• Secondary:dissolved lung from over-
oxygen in arterial
bloodstream (PaO2). expanding
This is the hypoxic
drive
 Message is Transmitted
• Two groups of nerves
connect the brainstem
to the muscles of
respiration:
– Phrenic nerve to
diaphragm (C4-C6)
– Thoracic spinal nerves
to intercostal muscles
(T1-T12)
 Chest Wall
• Chest wall creates
negative
intrathoracic
pressure
– diaphragm (80%)
– increased thoracic
diameter
• Air enters airways to
fill the newly created
space
 Inspiration
• Increased
intrathoracic space
• Negative pressure
• Bronchioles dilate
• Air enters
airways/alveoli
(unless a hole is
present in the chest
wall)
 Expiration
• Diaphragm &
intercostals relax
• Thoracic space gets
smaller
• Increased
intrathoracic pressure
• Air passively exits via
airways
 What Happens to the Airways?
• Smooth-muscle lined Inspiration
airways (bronchioles)
naturally change
diameter with
inspiration and
expiration
• (This will be Expiration
important when we
discuss obstructive
lung disease)
 Upper Airways
• Function
– Protection
– Humidification
– Filtration
• Structures
– Nasopharynx
– Oropharynx
– Tongue
– Epiglottis
– Larynx
 Lower Airways
• Function
– Filtration
– Transmission of air
• Structures
– Trachea
– Mainstem bronchi
– Bronchioles
– Terminal bronchioles
 What can go Wrong?
Ventilation may be impaired by the
following disorders:
• Neurologic
• Chest wall impairment
• Upper airway obstruction
• Lower airway obstruction
 Perfusion
• Definition of perfusion:
adequate blood flow
through the pulmonary
capillary bed
R Heart L Heart
• Components:
– Intact pulmonary
capillary bed
– Adequate cardiac
function
– Adequate blood volume
 Pulmonary Capillary Bed
May be damaged by:
• Clots (pulmonary
emboli)
• Crushing injuries R Heart L Heart
(pulmonary
contusion)
 Cardiac Function
• The pulmonary
capillary bed is part of
the cardiopulmonary
circuit
• Impairment of flow
through any chamber
or valve will impact
pressures and flow
 Blood Volume
• Adequate perfusion
requires adequate
blood volumes AND
composition
• Reduction of volume,
or decreased/
inadequate RBCs will
diminish perfusion
 Pulse Pressure
• The pulse pressure is the change in
pressure from the diastolic level to the
systolic level.
• It is determined by two factors, the stroke
volume and the compliance of the arterial
system.
• PP=SP−DP
• pulse pressure in healthy adults, sitting
position, is about 30–40 mmHg.
• A pulse pressure is considered abnormally
low if it is less than 25% of the systolic
value.
• The most common cause of a low (narrow)
pulse pressure is a drop in left ventricular
stroke volume.
• In trauma a low or narrow pulse pressure
suggests significant blood loss (insufficient
preload leading to reduced cardiac output).
• If the pulse pressure is extremely low, i.e.
25 mmHg or less, the cause may be low
stroke volume, as in Congestive Heart
Failure and/or shock.
• A narrow pulse pressure is also caused by
aortic valve stenosis and cardiac
tamponade.
• The pulse pressure increases with exercise
due to increased stroke volume, healthy
values being up to pulse pressures of about
100 mmHg, simultaneously as total
peripheral resistance drops during exercise.
In healthy individuals the pulse pressure
will typically return to normal within about
10 minutes.
• If the usual resting pulse pressure is
consistently greater than 100 mmHg, the
most likely basis is stiffness of the major
arteries, aortic regurgitation (a leak in the
aortic valve), arteriovenous malformation
(an extra path for blood to travel from a
high pressure artery to a low pressure vein
without the gradient of a capillary bed),
hyperthyroidism or some combination.
• While some drugs for hypertension have
the side effect of increasing resting pulse
pressure irreversibly, other
antihypertensive drugs, such as ACE
Inhibitors, have been shown to lower pulse
pressure.
• A high resting pulse pressure is harmful
and tends to accelerate the normal aging of
body organs, particularly the heart, the
brain and kidneys.
• A high pulse pressure combined with
bradycardia and an irregular breathing
pattern is associated with increased
intracranial pressure and should be
reported to a physician immediately. This
is known as Cushing's triad and can be
seen in patients after head trauma related to
intracranial hemorrhage or edema.
 Mean Arterial Pressure
• defined as the average pressure in a
patient’s arteries during one cardiac cycle.
It is an indicator of perfusion to vital
organs.
• True MAP can only be determined by
invasive monitoring and complex
calculations; however it can also be
calculated using a formula of the SBP and
the diastolic blood pressure (DBP).
• At normal resting heart rates M A P can be
approximated using the more easily
measured systolic and diastolic pressures,
S P and D P
• M A P ≃ D P + 1/3 ( S P − D P ) or
equivalently
• M A P ≃ 2/3 ( D P ) + 1/3 ( S P ) or
equivalently
• M A P ≃(( 2 × D P ) + S P )/3 or
equivalently
• M A P ≃ D P + 1/3 P P
• M A P is considered to be the perfusion
pressure seen by organs in the body.
• It is believed that a M A P that is greater
than 70 mmHg is enough to sustain the
organs of the average person.
• M A P is normally between 65 and 110
mmHg
• If the M A P falls below this number for an
appreciable time, vital organs will not get
enough Oxygen perfusion, and will
become hypoxic, a condition called
ischemia.
 What can go Wrong?
Perfusion may be impaired by the following
disorders: :
• Damaged pulmonary circulation (pulmonary
embolus or contusion)
• Diminished cardiac function (left heart
failure)
• Inadequate blood volume (hypovolemia;
sickle-cell anemia)
 Diffusion
– Definition of diffusion:
movement of gases
between the alveoli and
the pulmonary capillary
bed
– Components:
• Alveolus
• Basement membrane
(interstitial space)
• Capillary wall
 Alveolus
• 100 million alveoli in
each lung
• Single cell thick wall
• Immediately adjacent
to pulmonary
capillary
• Gas exchanges via
diffusion
 Diffusion?
• The passive exchange Before diffusion
of gases along a
concentration gradient O2
CO2 CO2

(high to low)
O2

• Exchange continues
until the
concentrations are After diffusion
equal
O2
O2
CO2
CO2
 Basement Membrane
• Includes the walls of the
alveolus and capillary
• Most importantly,
includes the interstitial
space between the walls
of the capillary and
alveoli
• Drainage via lymphatics
 Capillary Wall
• If capillary wall is
thickened, diffusion
will be impaired
• If capillary wall is
damaged, diffusion
will be impaired
 What can go Wrong?
Diffusion may be impaired by the
following disorders: :
• Alveolar damage
• Widened basement membrane
• Thickened capillary wall
 Why Do We Care?
• Understanding these three functions of
the pulmonary system will allow you to:
– Categorize the problem (based on PMH
or chief complaints)
– Perform an intelligent assessment:
• Ventilation: look, listen, feel; breath sounds
• Perfusion: blood pressure, pulse, evaluation of
blood volume
• Diffusion: breath sounds, pulse oximeter
 And-- better yet--
You’ll be able to provide generic treatment based
on the physiology:
Ventilation: Diffusion:
• open the upper & lower • high flow oxygen
airways
• provide ventilation
• reduce fluid in
interstitial space
Perfusion:
• maximize cardiac output
and blood volume
• high flow oxygen
 Airway
• Visible obstruction
• Noise is obstruction!
• Physical positioning
• Secretions
• Evidence of trauma
(although not our
focus today)
Breathing
• Respiratory effort?
• Retractions?
• Rate and rate trends
• Air movement (look,
listen, feel;
stethoscope later)
 Circulation
• Remember the
relationship between
perfusion and
pulmonary function
• Skin color? Pallor,
diaphoresis, cyanosis
all suggest circulatory
failure