RESPIRATION

Saniya Firdose
1st year PG
OMFS
CONTENTS
INTRODUCTION
ANATOMY
PULMONARY VENTILATION
PULMONARY VOLUMES
PULMONARY CAPACITIES
RESPIRATORY SOUNDS
REGULATION OF RESPIRATION
CLINICAL ASPECTS
INTRODUCTION
THE RESPIRATORY SYSTEM
– OXYGEN DELIVERY
SYSTEM
An integrated system of
organs involved in the
intake and exchange of
oxygen and carbon dioxide
between the body and
environment
Conducting zone
• From nose to the terminal
bronchioles
• Does not participate in gas
exchange
• Function – inspire, warm,
humidify and filter the air
before gas exchange
• Smooth muscle layer –
innervations from
sympathetic and
parasympathetic nerve
fibers
Respiratory zone
• From terminal bronchioles to the alveoli
• Lined with alveoli
• Gas exchange
NOSE-
Nasal vibrissae coated with mucous – traps dust
particles or pollen etc
Humidifies filters the inspired air, and voice resonance
Houses olfactory receptors.
NASAL CAVITY-
Divided into two halves by –
anteriorly – septal cartilage
posteriorly – vomer bone
Nasal conchae – mucosa-covered bony projections –
superior
Middle
inferior
Lined by two types of mucous membranes –
olfactory mucosa
respiratory mucosa
Palate-
Separates the nasal cavity from the oral cavity- Hard palate
Soft palate
Soft palate – uvula move together to form a valve – closes the nasopharynx while
swallowing
Pharynx-
Larynx-
Trachea-
Lungs-
Bronchioles-
Alveoli-
Muscles of Respiration
The four major components pulmonary ventilation
of respiration are the
following:
Diffusion of oxygen (O2)
and carbon dioxide (CO2)
between the alveoli and
the blood

transport of oxygen and

carbon dioxide in the
blood and body fluids to
and from the body’s
tissue cells

regulation of ventilation
MECHANICS OF PULMONARY
VENTILATION
PRESSURES THAT CAUSE MOVEMENT OF AIR
IN AND OUT OF THE LUNGS
• Tidal volume - the volume of air inspired or expired with
each normal breath; it amounts to about 500 ml in the
average healthy man
• Inspiratory reserve volume - the extra volume of air
that can be inspired over and above the normal tidal
volume when the person inspires with full force; it is usually
equal to about 3000 ml.
• Expiratory reserve volume- the maximum extra volume
of air that can be expired by forceful expiration after the
end of a normal tidal expiration; this volume normally
amounts to about 1100 ml in men.
• Residual volume- the volume of air remaining in the
lungs after the most forceful expiration; this volume
averages about 1200 ml
• Inspiratory capacity- This capacity is the amount of air (≈3500
ml) that a person can breathe in, beginning at the normal expiratory
level and distending the lungs to the maximum amount.
=tidal volume+inspiratory reserve volume
• Functional residual capacity- This capacity is the amount of air
that remains in the lungs at the end of normal expiration ≈2300 ml).
=expiratory reserve + residual volume.
• Vital capacity- This capacity is the maximum amount of air a person
can expel from the lungs after first filling the lungs to their maximum
extent and then expiring to the maximum extent (≈4600 ml).
=inspiratory reserve volume + tidal volume + expiratory reserve
volume.
• Total lung capacity- the maximum volume to which the lungs can
be expanded with the greatest possible effort (≈5800 ml)
=vital capacity + residual volume.
PULMONARY VOLUMES AND CAPACITIES
Respiratory sounds
Tracheal Breath Sounds- breath sounds are loud and high-pitched and are
heard primarily over the trachea
Bronchial sounds- Bronchial sounds are produced by air rushing through the
larger bronchi.
Vesicular breathing sounds- Vesicular breathing sounds occur as air fills the
alveoli, and they are soft and resemble a muffled breeze.
Wheezing- high whistling sounds in the lungs, and it is usually more
pronounced with expiration
Squawks- very short wheezes that usually occur late during inspiration.
Stridor- high-pitched sound with a musical quality that is heard mostly with
inspiration
Rhonchi- low-pitched clunky or rattling sounds, sometimes resembling
snoring.
Rales or Crackles- crepitation
Whooping Cough- high-pitched "whoop" sound may be heard after coughing
Pleural Rub – walking on fresh snow
Control of Respiration
Neural Regulation-
• Phrenic and intercostal nerves
• Medulla and pons

Non-neural Factors Influencing Respiratory Rate and

Depth
Physical factors
Emotional factors
Chemical factors
• Mechanoreceptors – pulmonary stretch receptors in smooth muscles of
airways (Hering–Breuer inflation reflex)
Defensive respiratory reflexes - response to inhaled irritants
• Cough reflex
• Reflex tachypnoea and bronchoconstriction
• Sneeze reflex
Clinical implications
Aspiration - Aspiration or ingestion of instruments or materials used in
dentistry is a relatively common risk during many dental procedures.
Items that are more commonly accidentally inspired or swallowed include
teeth, restorations and restorative materials, instruments, implant parts,
rubber dam clamps, impression materials, and crowns.
 ASTHMA
Asthma is classically defined as bronchial hyper-responsiveness and
reversible bronchoconstriction due to smooth muscle contraction leading
to diminished ventilation and hypoxia.
Signs and symptoms:
• shortness of breath
• nocturnal awakenings
• limitation in activity
• wheezing that is predominantly expiratory
• Cough
• chest tightness
• status asthmaticus
The goal of treating the asthmatic patient is to maintain all preoperative
medications
• Short-acting beta agonist (SABA) (eg, albuterol metered dose inhaler[MDI] as
needed)
• Corticosteroid (eg, fluticasone MDI twice a day)
• Long-acting beta agonist (LABA) (eg, salmeterol MDI twice a day)
• Leukotriene receptor antagonist (eg, montelukast orally daily)

Perioperative exacerbations of asthma may be serious. The treatment of

exacerbations includes:
• SABA such as albuterol metered dose inhaler (MDI) or nebulizer (2.5 mg/ 5 mL
normal saline [NS]) every 4 to 6 hours as needed
• Anticholinergic medication (eg, ipratropium MDI or nebulizer (0.5 mg/5mL NS)
every 6 hours as needed
• Corticosteroid burst (prednisolone 1 mg/kg/d orally for 5 days)
Chronic Obstructive Pulmonary Disease
• Emphysema- Emphysema is characterized by dilated and collapsed airways with
alveolar destruction secondary to alpha1-antitrypsin deficiency as a result of smoking
or a congenital deficiency
• Chronic bronchitis- increased airway secretions and mucous production.
• The net result of both diseases is the retention
of CO2 and eventually hypoxia.
• The signs and symptoms of COPD are :
Hyperventilation
barrel chest
pursed lips
decreased breath sounds
• A patient with emphysema is often described
as a “pink puffer,”
• Patient with chronic bronchitis is often
described as a “blue bloater.”
• The diagnosis of COPD can be made with:
Pulmonary function tests (spirometry)
• —Decrease in FEV1 (proportional to severity)
• —No change in vital capacity
• —Decrease in the ratio of FEV1 to FVC to less than 70% of the predicted value
Arterial blood gas
• —Increase in PCO2 and possible decrease in PO2, respiratory alkalosis
Chest radiograph
• —Loss of lung markings, hyperinflation, and flattened diaphragm
Management of perioperative exacerbations
1. Ambulatory oxygen (including home O2) at 2 to 6 L/min with a nasal
cannula or 6 to 10 L/min with facemask
2. SABA such as albuterol MDI or nebulizer (2.5 mg/5 ML NS) every 4 to
6 hours as needed
3. Anticholinergic medication (eg, ipratropium MDI or nebulizer (0.5 mg/5
mL NS) every 6 hours as needed
4. Corticosteroid burst (prednisolone 1 mg/kg/d orally for 5 days)
Pneumonia
The term pneumonia includes any inflammatory condition of the lung
in which some or all of the alveoli are filled with fluid and blood cells.
A common type of pneumonia is bacterial pneumonia, caused most
frequently by pneumococci.
It can be associated with the use of mechanical ventilation, at which
time it is referred to as ventilator-associated pneumonia.
• The diagnosis is best made with:
Chest radiograph or computed tomography (CT) scan
• —Infiltration or consolidation of lung parenchyma
• —Pleural effusion
Bronchoalveolar lavage
• —Cultured organisms
Arterial blood gas
• —Decrease in PO22
Complete and differential blood cell count
• —Increase in white blood cell count
Positive blood culture
Pulmonary Embolism
• More than 95% of pulmonary emboli (PE) are from the deep veins of the legs. These
travel to the lungs, leading to respiratory and cardiovascular compromise
• Risk factors include :
o Smoking
o Use of contraceptive devices
o Pregnancy
o Tumors
o Hereditary coagulation disorders
The treatment of suspected PE may include one of the following:
1. Heparin IV with 50 mg/kg bolus or 12 mg/kg/h drip
2. Enoxaparin (1 to 1.5 mg/kg subcutaneously [SC] twice a day)
3. Fondaparinux (5 to 10 mg SC every day)
Atelectasis
• Atelectasis is a common postoperative complication characterized by a segmental
collapse of the lung alveoli
• Common causes of atelectasis are (1) total obstruction of the airway
(2) lack of surfactant in the fluids lining the
alveoli
• The signs and symptoms:
 decreased breath sounds
 inspiratory crackles at the bases
 labored breathing
 low-grade fever
Pneumothorax
A pneumothorax is a
collection of air outside the
lung but within the pleural
cavity.
It occurs when air
accumulates between the
parietal and visceral pleura
inside the chest.
The air accumulation apply
pressure on the lung and make
it collapse
Flail chest
Respiratory alkalosis
Respiratory alkalosis is an alkali imbalance in the body
caused by a lower-than-normal level of carbon dioxide in the
blood
Respiratory acidosis
Respiratory Acidosis is an acid-base imbalance characterized
by the increased partial pressure of arterial carbon dioxide
and decreased blood pH
Cyanosis
• The term cyanosis means blueness of the skin; its cause is
excessive amounts of deoxygenated hemoglobin in the
skin’s blood vessels, especially in the capillaries
• Central cyanosis - occurs when the level of
deoxygenated hemoglobin in the arteries is above 5 g/dL
with oxygen saturation below 85%. The bluish hue is
generally seen over the entire body surface and visible
mucosa
• Peripheral cyanosis - there is a significant difference in
the saturation between the arterial and venous blood.
• This occurs as a result of increased oxygen extraction by
the peripheral tissue in the capillary bed.
• Peripheral cyanosis is usually only seen in the upper and
lower extremities where the blood flow is less rapid.
HYPERCAPNIA
• EXCESS CARBON DIOXIDE IN THE BODY FLUIDS
• hypercapnia usually occurs in association with hypoxia only when the
hypoxia is caused by hypoventilation or circulatory deficiency
HYPOXIA
Hypoxia is a condition in which the body or a region of the body is
deprived of adequate oxygen supply at the tissue level.
Effects of Hypoxia on the Body-
• Depressed mental activity, sometimes culminating in a coma
• reduced work capacity of the muscles
OXYGEN THERAPY IN DIFFERENT TYPES OF HYPOXIA
O2 can be administered by the following-
• placing the patient’s head in a “tent” that contains air
fortified with O2;
• allowing the patient to breathe pure O2 or high
concentrations of O2 from a mask
• Administering O2 through an intranasal tube.
Dysbarism
Artificial respiration
• MANUAL • MECHANICAL
1) HOLGER NIELSON METHOD 1) RESUSCITATOR
2) MOUTH TO MOUTH BREATHING 2)TANK RESPIRATOR (the “Iron
Lung”)
3) VENTILATION
RESUSCITATOR

TANK RESPIRATOR
BOYLE’S APPARATUS
References
• GUYTON AND HALL TEXTBOOK OF PHYSIOLOGY 14TH ED – John E Hall,
Michael E Hall
• CLINICIAN’S HANDBOOK OF ORAL AND MAXILLOFACIAL SURGERY –
Daniel M Laskin, Eric R Carlson
• SCULLY’S MEDICAL PROBLEMS IN DENTISTRY – Crispian Scully
• ATLAS OF HUMAN ANATOMY – Frank H Netter