Cardiovascular and pulmonary
physiology
Mechanics of Breathing 1
What is pulmonary mechanics?
• pulmonary mechanics—the principles of
physics of that explains the interactions of the
lungs, airways, and chest wall
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4b08-b6d6-b3c7396b5fa3@5/Breathing
Muscles of inspiration
Muscles of Inspiration
Quiet breathing occurs when the diaphragm and the external intercostals muscles contract.
When the depth and frequency of inspiration increases, such as during exercise, the
sternocleidomastoid and the scalenes muscles contract.
Muscles of expiration
Muscles of Expiration
Normal quiet respiration results from relaxation of the diaphragm. Force expiration results when
the internal intercostals and the abdominal muscles contract.
Properties
of the lungs
Static Dynamic
• When we study the mechanics of the lung
while there is no air moving in and out of the
lungs we are studying the
• When we study the mechanics of the lungs
while there is air moving in and out of the
lungs we are studying the
Static properties of the lungs
• Lung volume is determined by the interaction
between the lungs and the thoracic cage
• The lungs have a tendency to collapse inwards
because of their elastic recoil
• The chest wall pulls outwards because of its
elastic recoil
Static properties of the lungs
• This interaction between lungs and chest wall
does not occur by direct attachment but
through the intrapleural space between the
visceral and parietal pleurae
Static properties of the lung
Rule!
• The Balance Between the Outward Elastic
Recoil of the Chest Wall and the Inward
Elastic Recoil of the Lungs Generates a
Subatmospheric Intrapleural Pressure
• Because the lungs and chest wall pull away
from each other on opposite sides of the
intrapleural space, the intrapleural pressure
(PIP) is less than barometric pressure (Pb)
• the intrapleural space is a relative vacuum
• So we will think of PIP as the intrathoracic
(intrapulmonary) pressure, that is:
• the pressure everywhere in the thorax except
in the lumens of blood vessels, lymphatics, or
airways.
Pressure gradient
• The vacuum is not uniform throughout the
intrapleural space.
• When the subject is upright, the vacuum is
greatest near the apex that means PIP is least.
Boyle’s law
Movement of
Volume of the Intrapulmonary Direction of air
the diaphragm
thoracic cavity pressure movement
and the ribcage
Inspiration
The diaphragm Air then flows
the
moves down The volume of from high
intrapulmonary
and the rib the thoracic pressure to low
pressure
cage moves up cavity increases pressure
decrease
and out (Inspiration)
Movement of
Volume of the Intrapulmonary Direction of air
the diaphragm
thoracic cavity pressure movement
and the ribcage
Expiration
Air then flows
The diaphragm The volume of the
from high
moves up and the thoracic intrapulmonary
pressure to low
ribcage moves cavity pressure
pressure
down and in decreases increase
(expiration)
Pressure changes during inspiration
and expiration
Mechanics of breathing
References
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earning.html
Physiology of the cardiovascular
system
Mechanics of breathing 2
Static mechanics
• The ease with which the lungs are inflated
during inspiration is known as compliance
• Compliance is defined as the volume change
per unit of pressure change
• The elastance of the lungs, which is a measure
of their elastic recoil, is the reciprocal of the
compliance (E = 1/C).
• Lungs with a high compliance have a low
elastic recoil, and vice versa.
What determines the static
compliance of the lungs?
The elasticity of pulmonary cells and
the extracellular matrix (accounts for
small part).
surface tension (responsible for a
large fraction of the lung’s elastic
recoil).
Surface tension
• Surface tension is a measure of the force
acting to pull a liquid’s surface molecules
together at an air-liquid interface
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3A_Liquids_and_their_Interfaces
Keep in mind !
• At equilibrium, the tendency of increased
pressure to expand the gas bubble balances
the tendency of surface tension to collapse it.
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• Smaller alveoli tend to collapse into larger
ones. How this is overcome in our lungs:
• pulmonary surfactant minimizes this
collapsing tendency by lowering surface
tension.
• each alveolus is tethered to adjacent alveoli,
which help hold it open—the principle of
interdependence.
• The term surfactant means a surface-active
agent.
• Because surfactants have both a hydrophilic
region (strongly attracted to water) and a
hydrophobic region (strongly repelled by
water), they localize to the surface of an air-
water interface.
• Pulmonary surfactant is a complex mixture of
lipids and proteins.
Dynamic mechanics
• When air is flowing—that is, under dynamic
conditions—one must not only exert the force
necessary to maintain the lung and chest wall
at a certain volume (i.e., static component of
force) but also exert an extra force to
overcome the inertia and resistance of the
tissues and air molecules (i.e., dynamic
component of force).
Airflow
Difference between alveolar
and atmospheric pressure
Airway
resistance Airflow
• In normal individuals, RAW is ∼1.5 cm
H2O/(L/s) but can range from 0.6 to 2.3.
• Resistance values are higher in patients with
respiratory disease and can exceed 10 cm
H2O/(L/s) in extreme cases.
• transpulmonary pressure is the difference
between alveolar and intrapleural pressure
(PTP = Pa − PIP).
• What is the physiological significance of these
three pressures, and how do we control
them?
Intrapleural pressure
• PIP is the parameter that the brain—through
the muscles of respiration—directly controls.
• Rearranging the definition of PTP in previous
Equation :
PIP = (−PTP)+ PA
• Thus, PIP has two components, −PTP and Pa.
• Intrapleural pressure has a static component
(−PTP) that determines lung volume and a
dynamic component (PA) that determines
airflow
Transpulmonary Pressure
• PTP is a static parameter. It does not cause
airflow.
• It determines lung volume along with the
static compliance
• the PTP is required to overcome the elastic
(i.e., static) forces that oppose lung expansion
• static compliance, is a property of the alveoli,
and that a decrease in C can produce
restrictive lung disease.
• PTP not only determines VL under static
conditions, when there is no airflow, but also
under dynamic conditions (i.e., during
inspiration and expiration).
• the brain does not directly control PTP.
Alveolar Pressure
• Pa is a dynamic parameter
• It does not determine VL directly.
• along with airway resistance, Pa determines
airflow.
• Pa required to overcome inertial and resistive
(i.e., dynamic) forces that oppose airflow
• airway conductance, the reciprocal of RAW, is
mainly a property of the conducting airways.
• A decrease in conductance can produce
obstructive lung disease.
Cardiopulmonary physiology
Ventilation, Diffusion, Perfusion
ventilation
• The process by which air moves into the lungs.
• Ventilation is gravity dependant
Supine position
• The apices and bases are ventilated
comparably.
• The lower most lung fields are better
ventilated than the uppermost lung fields
Upright position
• The bases are better ventilated than the
apices.
Side-lying position
• The dependant (lower) lungs are better
ventilated compared with the non dependant
(upper) lungs.
• How does that make sense when studying the
mechanics of ventilation
Remember that this represent the
resting lung volume
In the upright position
• Areas of the lungs with larger resting volumes
(apices) are less compliant, therefore the
volume change during ventilation is smaller.
• Areas of the lungs with smaller resting
volumes (bases) are more compliant,
therefore the volume change during
ventilation is larger.
Minute ventilation
• Total volume of air inspired or expired in one
minute.
• VE= Tidal volume × respiratory rate
• Normal minute ventilation = 12 x 500 ml =
6000ml
• Hypoventilation can occur with normal
respiratory rate
Alveolar ventilation
• VA = VT – anatomical dead space
• Approximately 350 ml per breath
Gas exchange
Conducting zone:
•Trachea to terminal bronchioles
•No gas exchange
•Gas transport
•Location of anatomical dead space
Respiratory Zone:
•Respiratory bronchioles to alveoli
•Gas exchange at alveolar-capillary membrane
•Gas transport by diffusion
•Large surface area
Diffusion
• The transfer of gas molecules (O2 and CO2)
across the alveolar capillary membrane.
• Oxygen diffuses slowly across the (A-C)
membrane in comparison to Carbon dioxide.
• Disease state results from thickening of the A-
C membrane.
• In diffusion problems Hypoxemia could coexist
with normal PCO2.
Example of diseases that decreases
the diffusion capacity
• Sarcoidosis
• Asbestosis.
• Scleroderma.
• Pulmonary edema
• emphysema
Perfusion
• The blood flow of the pulmonary circulation
available for gas exchange.
• The pulmonary circulation operates at
relatively low pressure compared to the
systemic circulation.
• The walls of the blood vessels are thinner than
comparable vessels in the systemic circulation.
The distribution of perfusion
• There is a nonuniformity of perfusion resulting
from the interaction between alveolar, arterial
and venous pressure across the lung fields.
• Normally blood flow is determined by
arteriovenous pressure gradient.
• In the lungs the pressure gradient affect the
arteriovenous pressure gradient.
Factors that influence blood flow in
the pulmonary circulation
• Hydrostatic pressure
• Arterial oxygen pressure
• Acid-base balance of blood
Cardio-Pulmonary Physiotherapy(1)
Pathophysiology of dyspnea
How did we learn about dyspnea?
• Our understanding of the physiologic
mechanisms underlying the sensations of
dyspnea is derived from studies employing a
range of experimental conditions in animals
normal subjects, anesthetized subjects, and
patients with cardiopulmonary and neurologic
diseases
Definition of dyspne
• A consensus statement of the American Thoracic
Society (ATS) has defined dyspnea as "a term
used to characterize a subjective experience of
breathing discomfort that is comprised of
qualitatively distinct sensations that vary in
intensity. The experience derives from
interactions among multiple physiological,
psychological, social, and environmental factors,
and may induce secondary physiological and
behavioral responses"
Respiratory motor command
corollary discharge
• There is a conscious awareness of the outgoing
respiratory motor command to the ventilatory muscles.
• This conscious awareness is attributed to a corollary
discharge from brainstem respiratory neurons to the
sensory cortex during automatic reflex breathing or
from cortical motor centres to the sensory cortex
during voluntary respiratory efforts.
• Evidence for corollary discharges is functional rather
than structural; specific receptors and pathways have
not been identified.
Respiratory motor command
corollary discharge
• These corollary discharges are thought to be
important in shaping the sense of respiration.
The sense of respiratory effort
Decreased muscle length.
muscle fatigue heightened
greater
respiratory muscle sense of
weakness motor
respiratory
command
effort
The sense of
respiratory effort
intensifies with
is proportional to the ratio of the pressures increases in
generated by the respiratory muscles to the
maximum pressure–generating capacity of central respiratory
those muscles
motor command
Chest wall receptors
• Projections to the brain of afferent signals
from mechanoreceptors in the joints,
tendons, and muscles of the chest play a role
in shaping respiratory sensations.
Evidence!
• Specifically, afferents from intercostal
muscles have been shown to project to the
cerebral cortex and contribute to
proprioception and kinesthesia
Pulmonary vagal receptors
• vagal inputs are important in shaping the
pattern of breathing.
• Dyspnea associated with bronchoconstriction
is in part mediated by vagal afferents
Evidence!
• Patients with high cervical spinal cord
transection, in whom feedback from chest wall
receptors is blocked, are able to detect changes in
tidal volume delivered by a mechanical ventilator,
and experience a sensation of air hunger when
their inspired volume is reduced.
• This suggests that vagal receptors may contribute
to the unpleasant sensations that result when
thoracic expansion is limited and to the dyspnea
that accompanies breath holding.
Chemoreceptors
• The dyspnea associated with hypercapnia and
hypoxia is largely the result of the chemically
induced increases in respiratory motor
activity.
• There is some evidence that the sensation of
dyspnea may also be directly affected by
inputs from chemoreceptors.
Evidence!
• Both ventilator-dependent quadriplegics with
high cervical spinal cord transaction and
normal subjects paralyzed with
neuromuscular blocking agents experience
sensations of air hunger when PCO2 is
increased
Mechanisms of dyspnoea
1. Increased output from the respiratory centres
2. Stimulation of mechanoreceptors
3. Mechanical loading of the respiratory system
4. Neuromechanical dissociation
5. Impaired oxygen delivery or utilization
6. Neural activation associated with breathing
discomfort and the affective dimension of
dyspnea
The pathophysiology of dyspnea
• Group work.
• Refer to the reference article on e-learning. Select
one mechanism of dyspnoea. Read and discuss
• Select one rep from the group to feed back to the
class
• You are required to discuss the mechanism
involved in the sensation of dyspena and how it is
related to heightened sensation of dyspnea
Cardiopulmonary physiotherapy 1
Pulmonary physiology/ Control of
breathing 1&2
Dr. Rasha Okasheh
Aims of the session
• To introduce the regulatory mechanism of
respiration.
• To provide an overview of the respiratory control
system.
• To describe the types, distribution and function of
the respiratory receptors.
• To describe the types of responses evoked by the
respiratory receptors.
• To identify how the perception of respiration
occurs.
Why do we breath?
• Q: What is the function of the respiratory
control system?
• A: The respiratory control system functions to
satisfy the metabolic requirements of the
body.
Control of breathing 1
inspiration expiration Breathing
Depth of
breathing
Rate of
breathing
Inspiration:
expiration
Pattern of breathing
Activity 1
• You have 2 minutes and I want you to think of
the factors that control our breathing. Please
write them down on the flipchart.
Let’s visit our respiratory system
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ory.png
Lets visit our chest wall!
Lets visit our brain
Control of the movements of
breathing
Reflexes Behavioral
Automatic
Hering- Cortex
Breuer (Voluntary)
Pons reflex
Cough Limbic
reflex system
Medulla (Emotional)
Stretch Respiratory
reflex sensation
Automatic
Medullary respiratory centre
• Responsible for the basic sequence of
inspiration and expiration.
• Respirations are not normal in character.
Automatic
Pontine respiratory centre
• Prolonged inspiratory gasps
Apneustic
centre
• Inhibit the apneustic centre
Pneumotaxic • Inhibit the inspiratory
centre component of the medulla
Behavioural
The sensation and perception
of respiration
• Respiration is regulated by automatic centres
(brainstem) and also by voluntary signals
(cortex).
• Sensory information is relayed to higher brain
centers where central processing of
respiratory-related signals and contextual,
cognitive, and behavioral influences shape
the ultimate expression of the evoked
sensation.
The Function of the respiratory control
system
Respiratory motor activity originates from
clusters of neurons in the medulla
Efferent respiratory discharges activate the
ventilatory muscles.
What will the ventilatory muscles do?
The resulting breathing regulates the oxygen
and carbon dioxide tensions and hydrogen ion
concentration in the blood and body tissues
• How Does the respiratory control system
know that it has fulfilled its function? Slide 4
• Sensory information?
Types of respiratory receptors
Chemoreceptors Mechanoreceptors
• Peripheral in • Vagal receptors in
Blood (carotid and airways and lungs
aortic bodies) • Joint and muscle
• Central in Brain receptors in chest
(medulla) wall
The respiratory receptors
• Chemoreceptors in the blood and brain
• Mechanoreceptors in the airways, lungs, and
chest wall
• Both types of receptors are involved in the
automatic regulation of the pattern of
breathing. How?
Chemoreceptors
Central peripheral
Respond to Respond to
changes in changes in
CSF pH PCO2 and PO2
The Chemoreceptors
• Signals from these Chemoreceptors are
transmitted back to brainstem respiratory
centres that adjust breathing to maintain
blood-gas and acid-base homeostasis
Mechanoreceptors
Respiratory
Vagal
muscles
receptors
receptors
irritant receptors C fibers, found in
around the Muscle spindles in
pulmonary the interstitium of
the lung in the intercostal
stretch receptors epithelial cells of muscles .
in lung tissue the bronchial proximity to the
walls alveoli and Tendon organs in
pulmonary the diaphragm.
capillaries
Let’s play!
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Groups!
• Based on the information you were given
about the location of the receptors, I want you
to think type of stimulus could stimulate the
Mechanoreceptors receptors.
Example/ Pulmonary stretch receptors
Pulmonary Activated by:
stretch Lung tissue lungs
receptors expansion
Stimulation of
the vagal receptors/ Irritant receptors
activated by:
tactile stimulation
in the bronchial
around the mucosa.
Irritant receptors epithelial cells of high rates of air
the bronchial walls flow.
increases in
bronchial smooth
muscle tone
Stimulation of the
the vagal receptors/ C fibers
interstitium of the Activated by :
lung in proximity to increases in
C fibers
the alveoli and pulmonary interstitial
pulmonary capillaries and capillary pressure
Types of responses by
the mechanoreceptors /respiratory
muscles receptors
Respiratory Muscle Activated by:
muscles spindles Changes in
receptors Tendon organs muscle tension
Transmission of signals from
mechanical receptors
• Feedback of afferent information from lung
and chest wall mechanoreceptors provides
respiratory motor and pre-motor neurons
with important information regarding:
1. the mechanical status of the ventilatory
pump
2. changes in length and force of contraction of
the respiratory muscles.
• These signals allow adjustments to be made in
the pattern of brainstem respiratory motor
activity to compensate for:
1. changes in respiratory muscle function
2. Ventilatory system impedance.
The perception of respiration
Chemoreceptors • Chemical status of the body
and • Mechanical status of the
mechanoreceptors
ventilatory system
Efferent copies of • conscious awareness of
brainstem
respiratory centre the outgoing motor
motor output command
Home work
Choose one of the following:
1. create a mind map showing the process of
the automatic, reflex, and the behavioral
control of breathing.
Upload under the discussion created by me on
the E-learning.
Cardiorespiratory signs and
symptoms
Cough mechanisms
Dr. Rasha Okasheh
• Is cough normal or not?
• A cough can either be a reflex or a voluntary
action.
• Q: why do we cough?
• Normally the mucociliary escalator is
responsible for the clearance of secretions and
inhaled particulate matter.
• Cough becomes into action:
1. When the sputum is very thick
2. Inhalation of a foreign body
3. A bolus of food going down the airways
Cough pump
• Mucus is transported up against gravity by the
mucous blanket and propelled cephalad by
the action of the cough.
Practical tip!
• cough is most effective at high expiratory flow
rates and at high volumes.
• The cough is of limited value beyond the sixth
or seventh generation of airway branching.
Remember!
• A patient should never be asked to cough
repeatedly as a routine part of treatment.
• Why?
Complications of cough
• The irritation and narrowing of the airways during
the forced exhalation may cause bronchospasm
• Forced coughing can also increase blood
pressure and lower cardiac output
• Tussive syncope can occur when a patient goes
into a series of coughs in which the intrathoracic
pressure becomes so high that venous return to
the heart is impaired.
Practical tip!
• If the cough is dry and unproductive: Do not
encourage coughing
• If assessment demonstrate retained
secretions: encourage hydration (drinking
water), use airway clearance mobilization
techniques, and carefully evaluate the cough
Stages of cough
The first stage (Deep inspiration) requires
inspiring enough air to provide the volume
necessary for a forceful cough Inspiratory phase
The second stage (glottis closure) involves
closing of the glottis (vocal folds)
The third stage (muscles contraction) is the Compressive phase
active contraction of the abdominal and
intercostal muscles.
The fourth stage (forceful expiration)involves
opening of the glottis and forcefully expelling
the air. Expiratory phase
How do we cough
Cough reflex
Cough assessment
The assessment of the The assessment of the
nature of cough is quality of cough needs
usually performed to be performed during
during history taking. the physical
examination by
observing the
performance of the
cough
You need to assess the nature
and the quality of the cough
The quality of the cough
• Verify whether the cough is effective or not
(practical application)
The nature of cough
• Verify whether the cough is acute or chronic
• Verify whether the cough is productive or non
productive (dry), or wheezy.
• Impact on sleep or function
• Aggravating and relieving factors
• Identify the timing of the cough
• Identify the characteristics of the cough and link
it to the most common causes (table 8-4, page
132)
Most common causes of cough
• Asthma
• Smokers (chronic bronchitis)
• Post nasal drip
• Gastroesophageal reflux
• Various cardiac conditions
• Interstitial lung disease
• Allergies
• Viral or bacterial infections
• Bronchogenic carcinoma
• Swallowing problems (consider patients with neurological
problems)
• Some Medications.
Activity
• Refer to the handouts and in groups work on
the activity provided
Peter V. Dicpinigaitis, Leonard Lim, Constantine Farmakidis
Cough syncope
Respiratory Medicine, Volume 108, Issue 2, 2014, 244–251
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