Basics of

pulmonolgy
By Dr. Haitham Nabeel

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 Basic anatomy

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Respiratory tract

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Respiratory tract

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Respiratory tract
• Conducting Zone
• No gas exchange
• Large airways: nose, pharynx, trachea, bronchi
• Filters, warms, humidifies air
• Respiratory Zone
• Gas exchange
• Respiratory bronchioles, alveolar ducts, alveoli

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Mucous
• Secretions produced by respiratory tract
• Mostly glycoproteins and water
• Secreted by goblet cells in bronchial walls
• Protects against particulates, infection
• Beating cilia move mucous to epiglottis →swallowed

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Acinus

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Alveoli
• Small sacs
• Gas exchange
• Surrounded by capillaries

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Alveolar Cells: Pneumocytes
• Type 1
• Most common (97% of cells)
• Thin for gas exchange
• Type 2
• Produce surfactant
• Can proliferate to other cells –key for regeneration after
injury

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Surfactant
• Exhale →alveoli shrink
• Could collapse → atelectasis
• ↓ efficiency gas exchange
• Surfactant allows alveoli to avoid collapse

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Lobes

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Aspiration
• Right lung is more common site of aspiration
• Right bronchus wider
• Less angle
• More vertical path to lung

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Aspiration Foreign Body
• If upright
• Right inferior lobe –lower portion
• If supine (lying flat)
• Right inferior lobe –superior portion
• Right upper lobe –posterior segment

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Aspiration Foreign Body

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Hila

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Pulmonary artery

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Pleura

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Muscles of Quiet Respiration
• Diaphragm →inspiration
• Exhalation is passive with normal (“quiet”) breathing

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Exercise Breathing
• Inspiration (neck)
• Scalenes –raise ribs
• Sternocleidomastoids –raise sternum
• Exhalation (abdomen)
• Rectus muscle
• Internal/external obliques
• Transverseabdominis
• Internal intercostals
• Use of accessory muscles in respiratory distress
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Exercise Breathing

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 Basic physiology

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Lung volumes

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Lung volumes
• Tidal volume
• In/out air with each quiet breath
• Expiratory reserve volume
• Extra air pushed out with force beyond TV
• RV remains in lungs
• Inspiratory reserve volume
• Extra air can be drawn in with force beyond TV
• Lungs filled to capacity
• Residual volume
• Air that can’t be blown out no matter how hard you try
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Lung Capacities
• Capacity = sum of two volumes
• Total lung capacity
• Sum of all volumes
• RV + ERV+ IRV + TV
• Inspiratory capacity
• Most air you can inspire
• TV + IRV
• Vital capacity
• Most you can exhale
• TV + IRV + ERV
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Lung Capacities
• Functional Residual Capacity
• Residual volume after quiet expiration
• RV + ERV
• Volume when system is relaxed
• Chest wall pulling out = lungs pulling in

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Ventilation
• Ventilation = volume x frequency
• 500cc per breath x 20 breaths per minute
• 10,000cc/min
• Alveolar ventilation = useful for gas exchange
• Dead space ventilation = wasted ventilation
• Nose, trachea, other areas with no gas exchange

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Dead Space
• Space filled with air but no gas exchange
#1: Anatomic dead space
• Volume of conducting portions respiratory tract
• Nose, trachea
#2: Physiologic dead space
• Anatomic PLUS volume of alveoli that don’t exchange gas
• Insufficient perfusion
• Apex is largest contributor
• Physiologic dead space increases in many diseases
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Ventilation
• Total ventilation (TV) = volume/min out each breath
• Sometimes called minute ventilation
• Alveolar ventilation
• Fresh air for gas exchange
• TV minus “dead space”
• Imagine 500cc out per minute
• 150cc fills dead space
• Only 350cc available for gas exchange
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Pressures

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Pressures

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Alveoli and Pleural Pressures
Quiet (tidal) breathing

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Lung Compliance
• For given pressure how much volume changes
• Compliant lung
• Small amount diaphragm effort
• Generates small pressure change across lungs
• Large volume change
• Easy to move air in/out
• Non-compliant lung
• Large amount diaphragm effort
• Big pressure change across lung
• Small volume change (lungs stiff)
• Hard to move air in/out
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Lung Compliance

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 Ventilation & Perfusion

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A-a Gradient
• Hypoxemia with high A-a gradient
• Alveoli can’t get O2 to blood
• Blood not going to working alveoli
• Three basic mechanisms create the high A-a gradient
• #1: Diffusion limitation
• #2: Shunt
• #3: V/Q Mismatch
• Dead space →hypercapnia (↑CO2)
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Diffusion Limitation
• Increased A-a gradient
• Hypoxemia
• Less effect on CO2
• Seen in pulmonary fibrosis
• Hypoxemia
• Hypercapnia
• Destruction alveolar capillaries→ dead space
• Ventilation without perfusion
• Dead space may cause hypercapnia
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Ventilation-Perfusion
• Ideally ventilation to lung is matched by perfusion
• Ideal V/Q = 1
• Normal lungs:
• 4L/min air into lungs
• 5L/min blood into lungs
• V/Q = 0.8
• If V/Q too high or too low, ventilation is inefficient

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V/Q < 1
• Reduced ventilation relative to perfusion
• Perfusion wasted
• Blood going where not enough O2 present

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Shunting
• Extreme reduction in V/Q
• V/Q = 0
• Venous blood to arterial system without oxygenation
• Causes hypoxemia

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Shunting
• Anatomic shunting
• Blood bypasses lungs/alveoli completely
• Intra-cardiac, pulmonary AVMs
• Physiologic shunting
• Blood goes to alveoli that don’t work
• Non-ventilated alveoli are perfused
• One example: Atelectasis (collapsed airway)

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Shunting

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V/Q > 1
• Reduced perfusion relative to ventilation
• Ventilation wasted
• Gas going in where insufficient blood flow

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Dead Space
• Extreme increase in V/Q
• V/Q = ∞
• Anatomic dead space
• Volume of conducting portions respiratory tract
• Nose, trachea
• Physiologic dead space
• Anatomic PLUS volume of alveoli that don’t exchange gas
• Insufficient perfusion
• Apex is largest contributor
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Dead Space
• Physiologic dead space increases many diseases
• Poor perfusion of alveoli
• Fibrosis may cause dead space
• Destruction of alveolar capillaries
• Alveoli ventilated but under-perfused

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Dead Space

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V/Q Mismatch
• Intermediate state
• Some lung areas low V/Q
• Others high V/Q
• Inadequate ventilation
• Reduced oxygenation of blood
• ↑ RR → CO2 normal

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V-Q Mismatch
Pulmonary Edema

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Ventilation-Perfusion

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 Hypoxia

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Oxygen delivery to tissues
• Delivery = Cardiac Output * O2 Content of blood
• For proper O2 delivery need:
• Normal cardiac output
• Normal O2 content

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What determines O2 content?

#1: O2 binding capacity

• How much O2 blood can hold
• Determined by hemoglobin
#2: % Saturation
• % Hemoglobin molecules saturated
#3: Dissolved O2
• O2 directly dissolved in blood

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PaO2
• Partial pressure oxygen in blood
• Obtained from an arterial blood gas
• Reflects amount of O2 dissolved in blood
• Normal: >80mmHg

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Pulse Oximetry
• Measures % O2 saturation of blood
• Related to PaO2
• Uses light and a photodetector

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Hypoxemia, Hypoxia, Ischemia
• Hypoxemia: Low oxygen content of blood
• Hypoxia: Low O2 delivery to tissues
• Ischemia: Loss of blood flow

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Hypoxemia, Hypoxia, Ischemia
• Low O2 sat or low PaO2 = hypoxemia
• Hypoxemia→ hypoxia
• Can have hypoxia without hypoxemia (normal O2sat)
Some causes of hypoxia
Hypoxemia
Heart failure
Anemia
CO poisoning

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Heart Failure
• ↓ cardiac output
• ↓ blood flow to tissues→ hypoxia
• O2 content of blood may be normal
• PaO2 and O2sat may be normal

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Anemia
• Oxygenation of blood by lungs is normal
• Oxygen carrying capacity of blood reduced
• Low O2 content of blood
• PaO2 and O2sat normal

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Carbon Monoxide
• Binds to iron in heme -240x the affinity of oxygen
• Blocks O2 binding sites: “Functional anemia”
• Alveolar O2(PAO2) usually normal
• Amount of CO gas required for poisoning usually small
• Normal PAO2→Normal PaO2
• ↓ O2 binding to Hb despite normal PaO2
• Low O2sat (CO blocking O2binding sites)
• Pulse oximeter shows normal (100%) O2sat
• Can’t distinguish Hb bound to CO from that bound to O2
• O2content of blood reduced
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Alveolar gas

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A-a Gradient
• Difference between alveolar (A) and arterial (a) O2
• Helpful for evaluating hypoxemia
• Step 1: Measure PaO2, PaCO2
• Step 2: Determine PAO2 from gas equation
• Step 3: A-a gradient = PAO2–PaO2
• Normal 10-15mmHg
• Shunting from thebesian and bronchial veins

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A-a Gradient
• Hypoxemia with normal A-a gradient
• Alveoli working
• Not inhaling enough O2
• Hypoventilation
• Reduced respiratory rate
• Reduced tidal volume
• Narcotics, neuromuscular weakness, obesity
• High altitude
• Can treat with more oxygen
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A-a Gradient
• Hypoxemia with high A-a gradient
• Alveoli not working
• Can’t get O2 to blood
• Blood not going to working alveoli
• Most lung diseases have high A-a gradient
• Pneumonia, pulmonary edema, etc.
• Three basic mechanisms create the high A-a gradient
• Fibrosis
• Shunt
• V/Q Mismatch
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 Pulmonary function tests

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Pulmonary Function Testing
• Diagnosis of symptomatic disease

• Screening for early, asymptomatic disease

• Prognostication of known disease

• Monitoring response to treatment

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Pulmonary Dyspnea
• Obstruction
• Can’t get air out of lungs
• Air trapped
• Poor oxygenation
• Restriction
• Can’t get air into lungs
• Poor oxygenation

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Types of PFTs
Standard PFTs Specialized PFTs
Spirometry Arterial Blood Gas
)including flow-volume loop(
Exercise Oximetry
Lung Volumes
6 Minute Walk Test
Diffusing Capacity of
Carbon Monoxide (DLCO) Peak Flow

Maximum Inspiratory and

Expiratory Pressures

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Reporting PFTs
• Values are reported as a %
of that predicted (% Ref),
given the patient’s age,
gender, and height.

• “Normal” is generally
considered within ~80-
120% predicted, or between
5th and 95th percentile.
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Spirometry
• Method for assessing pulmonary function
• Pulmonary function tests (PFTs)
• Patient blows into machine
• Volume of air measured over time

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Spirometry

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Spirometry

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Spirometry

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Summary
• FEV1 and FVC fall in both obstructive and restrictive
diseases
• FEV1 falls MORE than FVC in obstructive
FEV1/FVC FVC FEV1
↓ ↓ ↓↓ Obstructive

or higher 80% ↓ ↓ Restrictive

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Volumes
• Spirometry can measure
• VC (FVC)
• IRV
• ERV
• Cannot measure
• RV
• FRC
• Residual volume rarely measured clinically
• Requires special techniques
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Flow Volume Loop

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Flow Volume Loop

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Flow Volume Loop

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Assessing Response to Bronchodilators

• Among patients with obstructive

lung disease, > 12-15% increase
in FEV1 after administration of a
bronchodilator is considered
significant.

• However, a lack of such an

increase should not preclude a
trial of bronchodilators.
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Lung Volumes

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How Are Lung Volumes Measured?
• Helium Dilution
Gas dilution techniques

• Nitrogen Washout

• Body Plethysmography

• Radiographic measurements (Chest X-ray or CT)

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Body Plethysmography

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Interpretation of lung volumes

Low FEV1/ FVC Obstruction

Low TLC Restriction

Obstruction
Low FEV1 / FVC and
and Restriction
Low TLC “Mixed Defect”

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Interpretation of lung volumes

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Diffusing Capacity of Carbon Monoxide (DLCO)

• DLCO is a rough surrogate for the overall function of

the alveolar-capillary membrane.

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Diffusing Capacity of Carbon Monoxide (DLCO)

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Diffusing Capacity of Carbon Monoxide (DLCO)

• Primary Indications for Measuring DLCO:

• To categorize a patient with restrictive lung disease as either probable ILD versus
extrathoracic restriction (e.g. obesity, neuromuscular disease).

• To identify early ILD in high-risk patients (e.g. chronic amiodarone use, history of
chest radiation, stage I sarcoidosis).

• To quantify anatomic emphysema in patients with COPD.

• To document disability for legal purposes.

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THANK YOU!

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