ANATOMI FISIOLOGI

PERNAPASAN

MUHDAR ABUBAKAR
DEPARTEMENT OF ANESTHESIOLOGY & REANIMATION
MEDICAL FACULTY OF GADJAHMADA UNIVERSITY
DR SARDJITO GENERAL HOSPITAL
YOGYAKARTA
INTRODUCTION

● A person can live for weeks without food and a few days
without water but only a few minutes without oxygen.
● Every cell in the body needs a constant supply of oxygen
to produce energy to grow, repair or replace itself, and
maintain vital functions.
● The oxygen must be provided to the cells in a way that
they can use.
● It must be brought into the body as air that is cleaned,
cooled or heated, humidified, and delivered in the right
amounts.
 THE BODY’S NEED FOR OXYGEN

Living tissue must have oxygen to survive.

Brain death in humans occurs within 6 to 10 minutes of
tissue anoxia.
Rapid and safe airway control is paramount to the
successful management of critically ill and injured
patients.
 Respiratory Physiology
Breathing
Respiration, has three basic steps:
 Pulmonary Ventilation the movement of air into and out of the
lungs
 External respiration: exchange of gases between the alveoli and
the blood in pulmonarry capillaries
 Internal respiration : exchange of gases between blood in
systemic capillaries and tissue cells
 Pressure in Thoracic Cavity
 Respiratory pressures are always described relative to
atmospheric pressure
 Boyle’s Law:
◦ Volume of gas is inversely proportional to pressure
◦ (if temperature constant)

Volume= Constant
Pressure
◦ So, when the volume of the container increases (expansion of
the lungs), the pressure decreases
 Boyle’s Law

 As the size of closed

container decreases,
pressure inside is
increase
 Pressure in Thoracic Cavity
 Atmospheric Pressure (Patm) - pressure exerted by
the air surrounding the body. At sea level its equal to
760mmHg.
 Intrapulmonary Pressure (Palv) - pressure exerted
by the air within the alveoli. It rises and falls during
inspiration and expiration, but it always equalizes with
atmospheric pressure.
 Intrapleural Pressure (Pip) - pressure within the
pleural cavity. It is always lower than both atmospheric
pressure and intrapulmonary pressure.
Lung Tissue

 It is elastic and has a

tendency to recoil
 Ribs want to expand
outward
 Lungs want to collapse

 Since the pressure in the plural space is lower than in

the alveoli, the alveoli do not collapse.
 Inspiration
 Contraction of the diaphragm and external
intercostal muscles increases the size of the
thorax (thereby decreasing the intra-pleural
pressure) and the lungs expand.
 Alveolar pressure falls below atmospheric
pressure.
 Intra-pleural (thoracic) pressure is always 4
mmHg less than the atmospheric pressure just
before inhalation (756 mm Hg)
 Inspiration

 Expansion of the lungs decreased alveolar

pressure to 758 mm Hg
 Atmospheric pressure is 760 mm Hg
 Air flows into the lungs because of this pressure
gradient
 Inspiration causes intra-pleural pressure to
decrease to 754 mm Hg
EXPIRATION

 Air is forced out of

the lungs as the
muscles relax
reducing the volume
of the chest cavity
and increasing the
pressure
 EXPIRATION
 Occurs when alveolar pressure is higher than
atmospheric pressure
762 mm Hg
 Elastic recoil of the chest wall and lungs (main force)
and the relaxation of the diaphragm increases intra-
pleural and alveolar pressure and decreases lung
volume
 Air moves out
 Quiet breathing does not take any effort (no muscles
are being contracted)
Pulmonary Ventilation
Other 3 Major Factors :
 Alveolar surface tension

 Compliance

 Airway resistance
 Alveolar surface tension

 Surface tension causes the alveoli to assume the

smallest diameter
◦ Major component of lung elastic recoil
 Surfactant is a phospholipid produced by Type II
cells in alveolar walls
◦ Alters surface tension below the surface tension of
pure water
◦ Prevents alveolar collapse following expiration
◦ If surface tension is too high, alveoli collapse and
great effort is needed to reopen them
 Compliance
Ratio of volume changes caused by pressure changes  V/P

• Lung Compliance
• Thoracic wall Compliance

Low compliance
To get desired volume there must be higher pressure

High compliance
Low pressure will give high tidal volume
COMPLIANCE (COMPL)

BALLOON

stiff Elastis

LOW HIGH
COMPLIANCE COMPLIANCE
Resistance
 The walls of the respiratory passageways have
resistance to the normal flow of air into the lungs
 The smaller the diameter, the greater the resistance
 Any condition that obstructs the air passageway
increases resistance, and more pressure is need to
force air through
 Asthma
 Inflammation due to infection
 COPD
AIRWAY RESISTANCE
(RAW)
BRONCHOCONSTRICTION:

PRESSURE
FLOW =
RESISTANCE

OBSTRUCTION:
 MUCUS / SECRET
 AIRWAY
RESISTANCE (RAW)
PRESSURE
TOO SMALL FLOW =
ETT
RESISTANCE

BRONCHOSPASM
TUMOUR / SECRET

COLLAPSE/ATELECTASIS
 Partial Pressure
 Dalton’s Law: each gas in a mixture of gases
exerts its own pressure as if all other gases
were not present
◦ Air 78% nitrogen, 21% oxygen, 1% other (CO2)
 Partial pressure of a gas is the pressure of an
individual gas in a mixture.
 PO2 21% X 760 = 159.6 mm Hg
 Total pressure is adding all the partial pressures
 Exchange of O2 and CO2

 O2 and CO2 Diffuse from areas of higher partial

pressures to areas of lower partial pressure
 Results in exchange of O2 and CO2 in the
alveoli
◦ Alveoli: PAO2=105 mm Hg, PCO2=40 mm Hg
◦ Capillaries: PvO2=40 mm Hg, PVCO2 =45 mm Hg
◦ Pulmonary vein:PAO2=100 PCO2=40 mm Hg
Exchange of O2 and CO2

O2 and CO2 Diffuse from areas of

higher partial pressures to areas of
lower partial pressure
The rate of pulmonary and systemic gas
exchange depends on several factors:

 Partial pressure difference of the gasses,

 Surface area available for gas exchange, in emfisema
surface area decreased  exchange decreased
 Diffusion distance, in pulmonary oedema, build up of
interstitial fluid between alveoli  distance higher,
exchange decreased
 Molecular weight and solubility of the gasses  CO2
diffusion occurs 20 X more rapid than O2, because
CO2 has 24X greater solubility and the molecular
weight 1,2 X greater than O2
The relationship between Hb saturation
and PO2  O2-Hb dissociation Curve
Other factors affecting Hb’s affinity for
O2
 Acidity (pH)  Lower pH will shift the O2-Hb
dissociation curve to the right, the affinity of Hb
for O2 decreased, O2 dissociates more easily
from Hb
 Partial pressure of CO2  As CO2 rises the
affinity of Hb for O2 decreased, O2 dissociates
more easily from Hb, shift the O2-Hb
dissociation curve to the right. PCO2 and pH
are related because low pH results from high
PCO2.
 Temperature, as temperature increases, so
does the amount of O2 released from Hb
, the O2-Hb dissociation curve shifted to
the right
 2,3 DPG, decreases the affinity of Hb for
O2, O2 dissociates more easily.
RELATIONSHIP BETWEEN VENTILATION (V)
AND PERFUSION (Q)
Normal V/Q = 1

V/Q > 1
V/Q < 1
alveolar dead space

shunt
 Lung volumes and Capacities
 Tidal Volume (TV) : The volume of one
breath, 6-8 ml/kgBW, average 500 ml
 Respiratory Rate (RR) : 12-16x breath/min
 Minute ventilation: total volume of inhaled
and exhaled each minute :
MV = TV x RR
= 12 x 500 ml = 6.000 ml = 6 liters/min
Next..
Alveolar Ventilation : the volume of air per
minute that actually reaches the
respiratory zone,
= ( tidal vol – dead space ) x RR
= ( 500 ml – 150 ml ) x 12
= 350 ml x 12 = 4200 ml/min
Lung volumes and Capacities
 Control of respiration
Respiratory Center, divided into 3 areas:
 Medullary rythmic area in medulla oblongata,to
control the basic rhythm. Nerve impulse in
Inspiratory area establish the basic rhythm. The
Expiratory area inactive during quiet breathing, active
during forceful breathing, impulse from these area
cause contraction of the intercostal and abdominal
muscles.
 Pneumotaxic area in pons  transmit
inhibitory impulses to the inspiratory
area, to turn off the inspiratpry area
before the lungs become too full of air.
 Apneustic Area in pons  send impulses
to the inspiratory area that activate it and
prolong inhalation  long deep inhalation
Control of respiration
Control of respiration
Chemoreceptor regulation of
respiration
 Central chemoreceptor : in medulla oblongata ,
respond to changes in H+ concentration or
PCO2 in CSF
 Peripheral chemoreceptor : located in aortic
and carotid bodiessensitive to changes in PO2,
H+ , and HCO3 -
 Respiratory physiology in paediatric
 There are several differences in the respiratory
physiology from the adult that can affect airway
management in the neonate and the infant:
Neonate Adult
(3 kg)
Oxygen consumption (ml/kg/min) 6-8 3.5
Carbon dioxide production (ml/kg/min) 6 3
Tidal volume (ml/kg) 6 6
Respiratory rate (per minute) 32-35 12-16
Vital capacity (ml/kg) 35 70
Finctional residual capacity /FRC (ml/kg) 30 35
 The increased O2 consumption & CO2
production make the neonate prone to
hipoxia  even small periods of apnea
during difficult airway management may not
well tolerated

 Reduced FRC and increased Closing Vol 

early closure of the airway during tidal
ventilation, reduced FRC limits O2 reserves
during periode of apnea & predispose to
atelektasis & Hypoxemia
 Work of breathing increased due to
higher resistance  narrow passage
 Hagen-Poiseuille formula:
Q = P x π x r4
8nl
Q = Flow through a tube ; r = radius ; l = length
P = Pressure ; n = viscosity
 Small reduction in the diameter of airway markedly
reduce the flow, increase the resistance, increase the
work of breathing
Problem ventilation in pediatric
1. Children obstruct more readily adults
The cricoid ring is the narrowest part of
pediatric airway.
2. Noxious intervention can lead airway
obtruction and precipitate respiratory
arrest
3. Positive presure via bag mask ventilation
cause opposite effect by stenting the
airway open and relieving the
obstruction
Anatomical Differences Between Adults and Children
Anatomy
Large intraoral tongue
High tracheal opening : C1 in infant, C3-
C4 at age 7, C4-C5 in adult
Large Occiput
Cricoid ring is the narrowest portion of
the trachea
Consistent anatomical variation
with age
Large tonsil and adenoid
Small cricoid membrane
Clinical Significance
Straight blade preferred over curved to
push distensible anatomy out of the way
to visualize larymx
High anterior airway position of the
glottic opening compared in adults
Sniffing position is preferred.The large
occiput actually elevated the the head
into sniffing position in infants and
children.
Uncuffed tubes provide adequate seal
Correct tube size essential
Younger than 2 years,high anterior;
2-8 years, trantition; older than 8 years,
small order
Blind nasotracheal intubation not
indicated in children
Needle cricothyrotomy difficult,
surgycalcricothyriromy imposible in
infants and small children
AIRWAY ANATOMY
Upper airway structures include the:
● Mouth
● Nose
● Pharynx (throat)
- Oropharynx
- Nasopharynx
- Laryngopharynx
● Larynx (voice box)

The lower airway structures include the:

● Trachea (windpipe) Vocal cords
● Bronchi (airways)
● Bronchioles
● Terminal bronchioles
● Alveoli
The upper airway functions to warm, filter, and humidify the air before
it enters the lower airway
The functions of the lower airway include air conduction, filtration,
warming, humidification, and removal of foreign particles.
Respiration occurs in the respiratory bronchioles of the lower airway
RESPIRATORY TRACTS AND STRUCTURE
● Mouth
● Nose
● Pharynx
- Oropharynx
- Nasopharynx conducting zone
- Laryngopharynx - cavities and tubes
- anatomic dead space
● Larynx
● Trachea
● Bronchi
● Bronchioles
● Terminal bronchioles

● Respiratory bronchioles
● Alveolar ducts
respiratory zone
● Alveolar sacs
● Alveoli
EXTERNAL NASAL
STRUCTURES

BONY FRAMEWORK
frontal bone
nasal bone
maxilla

CARTILAGINEUS
FRAMEWORK
lateral nasal cartilages
septal catrilages
alar cartilages

external nares (nostril)

fibrous connective and
adipose tissue
NOSE
AND NASAL CAVITIES superior
concha
frontal sphenoid
● Olfactory epithelium for sinus sinus
sense of smell
middle
concha
● Pseudostratified ciliated internal
nares
columnar with goblet cells
lines nasal cavity
inferior
concha
● Nose hairs at the entrance
to the nose trap large inhaled external
nares
particles.

● Nasal concha provide air turbulence and

promotes filtration and extra time for warming and humidifying air
PARANASAL SINUSES frontal sphenoid
sinus sinus

● to reduce the weight of the

skull,
● to produce mucus
● to influence voice quality by
acting as resonating chambers.
 hard palate
PHARYNX (THROAT)
external nares internal nares
nasal cavity
● connects nasal cavity with
larynx (± 5 inch) Soft
palate

● extends from the base of uvula

the skull to 6th cervical
vertebrae pharynx

● serves both the respiratory

and digestive systems
epiglottis

● three regions according to glottis

location:
- nasopharynx
- oropharynx
- laryngopharynx trachea

(hypopharynx).
 hard palate
NASO-PHARYNX
Soft
nasal cavity
palate
● from choanae to soft
palate
naso
● openings of auditory pharynx
(Eustachian) tubes from
middle ear cavity
uvula

● adenoids or
pharyngeal tonsil in roof

● area above where epiglottis

food enters thus towards glottis

the nasal cavity

● during swallowing, uvula projects upwards trachea

closing off passage to the nasal cavity
 hard palate

Soft
OROPHARYNX nasal cavity
palate

uvula
● the portion of the
pharynx that is posterior
to the oral cavity. oro
pharynx

● extends from soft

palate to the epiglottis
epiglottis
● area where both food
and air passes glottis

trachea
 hard palate
LARYNGO-PHARYNX
Soft
nasal cavity
palate
● posterior to the epiglottis and
extends to the larynx
uvula

● at larynx, food and air take

different passageways

laryngo
pharynx

epiglottis

glottis

Histology of the pharynx changes from

pseudostratified epithelium to stratified squamous
epithelium when going from naso-to oro-to laryngo- trachea
pharynx
LARYNX (VOICE BOX)
Epiglottis
Hyoid bone
Thyrohyoid membrane
Corniculate cartilage
Thyroid cartilage
(Adam’s apple)
Arytenoid cartilage
Crycothyroid ligament
Cricoid cartilage
Cricotracheal ligament
Thyroid gland
Parathyroid gland
Tracheal cartilage
BRONCHIALE TREE

The trachea and bronchi have

supporting cartilage to keep
airways open

Bronchiole walls contain

more smooth muscle,
a feature used in airflow
regulation
THE RESPIRATORY ZONE

● contains alveoli,
tiny walled sacs where
gas exchange occurs

● alveolar ducts end in

cluster of alveoli called
alveolar sacs

photomicrograph
 ALVEOLI AND PULMONARY CAPILLARIES
● The pulmonary artery carry
blood which is low in oxygen
from the heart to the lungs

● These blood vessel branch

repeatedly, forming dense
network of capillaries that
completely surround each
alveolus

● O2 and CO2 are

exchanged between the
aveoli and pulmonary
capillaries.

● Blood leaves the

capillaries via the pulmonary
vein which transport
oxygenated blood back to
the heart
alveolar macrophage

simple squamous epithelium

(type 1 cell)
surfactan secreting cell
(type 2 cell)

capillary
STRUCTURE OF THE RESPIRATORY
MEMBRANE

O2
CO2
O2

O2

CO2
VENTILATION AND RESPIRATION
IMPORTANT DEFINITIONS

Ventilation
the process of moving a volume of
gas in and out of the lungs

Respiration
● gas exchange (O2/CO2) across the
alveolar - capillary membrane
(external)
● or at the tissue/cellular level
(internal)
BOYLE’S LAW
relationship between pressure and volume

volume pressure volume pressure

pressure

volume
volume pressure
INSPIRATION

muscle contraction
EXPIRATION

Muscle relaxation
INTRAPULMONARY (INTRAALVEOLAR) PRESSURE
CHANGES
Intrapulmonary (intraalveolar) pressure is the pressure within the alveoli.
Between breaths, it equals atmospheric pressure (760 mmHg)
INTRAPULMONARY (INTRAALVEOLAR) PRESSURE
CHANGES
 INTRAPLEURAL PRESSURE

the pressure within the pleural cavity, always negatiive, and acts like a
suction to keep the lungs inflated

the negative intrapleural

pressure is due to:

• Surface tension of alveolar

fluid
• Elasticity of lungs
• Elasticity of thoracic wall
the negative intrapleural pressure is due to….

SURFACE TENSION OF ALVEOLAR FLUID

The surface tension of the alveolar

fluid tends to pull each of the alveoli
inward and therefore pulls the entire
lung inward. Surfactan reduce this
force
the negative intrapleural pressure is due to:

ELASTICITY OF LUNGS

the elastic tissue in the lungs tends

to recoil and pull the lungs inward.
As the lung moves away from the
thoracic wall, the cavity becomes
slightly larger, decreasing pressure
the negative intrapleural pressure is due to:

ELASTICITY OF THORACIC WALL

The elastic thoracic wall tends to

pull away from the lung, further
enlarging the pleural cavity and
creating this negative pressure

The surface tension of pleural

fluid resist the actual separation of
the lung and thoracic wall
INTRAPLEURAL PRESSURE CHANGES
INTRAPLEURAL PRESSURE CHANGES
FACTORS AFFECTING VENTILATION:

● resistance within the airways

● lung compliance
● thoracic wall compliance
RESISTANCE WITHIN THE AIRWAY

as air flow into the lungs, the gas molecules encounter

resistance when they strike the walls of the airway.
Therefore the diameter of the airway affects resistance

elastic fibres
smooth muscle
parasympatic neuron

histamin epinephrine
LUNG COMPLIANCE

The ease with which the lung expand is called lung compliance.
It is primary determined by two factors:
The stretchability of elastic fibres within the lungs
The surface tension within the alveoli
Comp : Δ V / Δ P
the stretchability of elastic
fibres within the lungs

the surface tension within

the alveoli
THORACIC WALL COMPLIANCE

● obesity
● intraabdominal distension
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