Introduction to Respiration

Respiration provides oxygen to the tissues and removes carbon dioxide. The
four major functions of respiration are,
➢ pulmonary ventilation, which means the inflow and outflow of air
between the atmosphere and the lung alveoli.
➢ diffusion of oxygen and carbon dioxide 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 and other facets of respiration.
Mechanics of Pulmonary Ventilation
The lungs can be expanded and contracted in two ways:
• by downward and upward movement of the diaphragm to lengthen or
shorten the chest cavity, and,
• by elevation and depression of the ribs to increase and decrease the
anteroposterior diameter of the chest cavity.
Normal quiet breathing is accomplished almost entirely by the first method,
that is, by movement of the diaphragm. During inspiration, contraction of the
diaphragm pulls the lower surfaces of the lungs downward. Then, during
expiration, the diaphragm simply relaxes, and the elastic recoil of the lungs,
chest wall, and abdominal structures compresses the lungs and expels the air.
During heavy breathing, however, the elastic forces are not powerful enough
to cause the necessary rapid expiration, so extra force is achieved mainly by
contraction of the abdominal muscles, which pushes the abdominal contents
upward against the bottom of the diaphragm, thereby compressing the lungs.
contd

The second method for expanding the lungs is to raise the rib cage. This
expands the lungs because, in the natural resting position, the ribs slant
downward, thus allowing the sternum to fall backward toward the vertebral
column. When the rib cage is elevated, however, the ribs project almost
directly forward, so the sternum also moves forward, away from the spine,
making the anteroposterior thickness of the chest about 20 percent greater
during maximum inspiration than during expiration.
Therefore, all the muscles that elevate the chest cage are classified as
muscles of inspiration, and those muscles that depress the chest cage are
classified as muscles of expiration. The most important muscles that raise the
rib cage are the external intercostals, but others that help are the
sternocleidomastoid muscles, which lift upward on the sternum; anterior
serrati, which lift many of the ribs; and scaleni, which lift the first two ribs.
The muscles that pull the rib cage downward during expiration are mainly the
abdominal recti, which have the powerful effect of pulling downward on the
lower ribs at the same time that they and other abdominal muscles also
compress the abdominal contents upward against the diaphragm, and
internal intercostals.
Lung Volumes and Lung Capacity
Lung volumes measurement is an integral part of pulmonary function test. Lung capacities
These volumes tend to vary, depending on the depth of respiration, ethnicity,
gender, age, body composition and in certain respiratory diseases. Lung Inspiratory capacity(IC)
volumes are also known as respiratory volumes. It refers to the volume of gas It is the maximum volume of air that can be inhaled following a resting state.
in the lungs at a given time during the respiratory cycle. Lung capacities are It is calculated from the sum of inspiratory reserve volume and tidal volume.
derived from a summation of different lung volumes. The average total lung IC = IRV+TV and value is around 3600 ml.
capacity of an adult human male is about 6 litres of air.
Lung volumes Total Lung Capacity(TLC)

Tidal Volume(TV) It is the maximum volume of air the lungs can accommodate or sum of all
volume compartments or volume of air in lungs after maximum inspiration.
It is the amount of air that can be inhaled or exhaled during one respiratory The normal value is about 6,000mL(4‐6 L). TLC is calculated by summation of
cycle[ This depicts the functions of the respiratory centres, respiratory the four primary lung volumes (TV, IRV, ERV, RV).
muscles and the mechanics of the lung and chest wall. The normal adult value Vital Capacity(VC)
is 10% of vital capacity (VC), approximately 300-500ml (6‐8 ml/kg); but can
increase up to 50% of VC on exercise. It is the total amount of air exhaled after maximal inhalation. The value is
Inspiratory Reserve Volume(IRV) about 4800mL and it varies according to age and body size. It is calculated by
summing tidal volume, inspiratory reserve volume, and expiratory reserve
It is the amount of air that can be forcibly inhaled after a normal tidal volume. volume. VC = TV+IRV+ERV.
IRV is usually kept in reserve, but is used during deep breathing. The normal VC indicates ability to breathe deeply and cough, reflecting inspiratory and
adult value is 1900-3300ml. expiratory muscle strength. VC should be 3 times greater than TV for
Expiratory Reserve Volume(ERV) effective cough.
It is the volume of air that can be exhaled forcibly after exhalation of normal Function Residual Capacity(FRC)
tidal volume. The normal adult value is 700-1200ml. ERV is reduced with It is the amount of air remaining in the lungs at the end of a normal
obesity, ascites or after upper abdominal surgery. exhalation. It is calculated by adding together residual and expiratory reserve
Residual Volume(RV) volumes. The normal value is about 1800 – 2200 mL. FRC = RV+ERV.
It is the volume of air remaining in the lungs after maximal exhalation. FRC does not rely on effort and highlights the resting position when inner and
Normal adult value is averaged at 1200ml(20‐25 ml/kg) .It is indirectly outer elastic recoils are balanced. FRC is reduced in restrictive disorders. The
measured from summation of FRC and ERV and cannot be measured by ratio of FRC to TLC is an index of hyperinflation. In COPD, FRC is upto 80% of
spirometry. TLC.
contd

VC = IRV + TV + ERV
VC = IC + ERV
TLC = VC + RV
TLC = IC + FRC
FRC = ERV + RV
IC = IRV+TV
Spirometry Protocol
A typical basic spirometer consists of a drum inverted over a chamber of
water, with the drum counterbalanced by a weight. In the drum is a
Spirometry is one of the pulmonary function tests; they are useful breathing gas, usually air or oxygen; a tube connects the mouth with the gas
investigations in the management of patients with respiratory disease or chamber. When one breathes into and out of the chamber, the drum rises
respiratory weakness secondary to neurological impairment. They aid and falls, and an appropriate recording is made on a moving sheet of paper.
diagnosis, help monitor response to treatment and can guide decisions
regarding further treatment and intervention. Spirometry can measure all the
lung volumes except residual volume. (RV constitutes part of FRC as well as
TLC and the procedures used for measurement of RV, FRC and TLC are based
on radiological, plethysmographic or dilutional techniques).
Indication
• Investigation of patients with symptoms/signs/investigations that suggest
pulmonary disease (e.g. cough, wheeze, breathlessness, crackles or
abnormal chest x-ray)
• Monitoring patients with known pulmonary disease for progression and
response to treatment (e.g. interstitial fibrosis, COPD, asthma or
pulmonary vascular disease)
• Investigation of patients with diseases that may have a respiratory
complications (e.g. connective tissue disorders or neuromuscular diseases)
• Preoperative evaluation prior to lung resection, abdominal surgery or
cardiothoracic surgery.
• Evaluating patients at risk of lung diseases (e.g. exposure to pulmonary Correct measurement posture is as follows:
toxins such a radiation, medication, or environmental or occupational
exposure) • Upright sitting: there is a difference in the amount of air the patient can
exhale from a sitting position compared to a standing position as long as
• Surveillance following lung transplantation to assess for acute rejection, they are sitting up straight and there are no restrictions and standing
infection or obliterative bronchiolitis. position is more better than supine lying
• Feet flat on the floor with legs uncrossed: no use of abdominal muscles
for leg position.
contd

• Loosen tight-fitting clothing

• Dentures normally left in: it is best to have some structure to the mouth area unless dentures are very loose.
• Use a chair with arms: when exhaling maximally, patients can become light-headed and possibly sway or faint.
• In the hospital setting, it may be impossible for the patient to sit in a chair, therefore, the position of the patient (usually
supine) should be the same and documented for future testing.
Technique
There are a number of different techniques for performing spirometry. However, most commonly the patient takes a deep
breath in, as large as possible, and blows out as hard and as fast as possible and keeps going until there is no air left. The
patient needs to keep blowing until no more air comes out. Some patients, particularly those with obstructive disease, may
find it difficult to exhale completely on a forced manoeuver.
PEF is obtained from the FEV1 and FVC manoeuver. Peak flow measurement is a quick test to measure air flowing out of
the lungs. The measurement is also called the peak expiratory flow rate (PEFR) or the peak expiratory flow (PEF). In men,
readings up to 100 L/min lower than predicted are within normal limits. For women, the equivalent figure is 85 L/min.
Forced vital capacity (FVC), involves inhaling and filling the lungs with as much air as possible, then exhaling with as much
force as possible.
Forced expiratory volume in 1 s (FEV1), measures the amount of air exhaled during the first second of the FVC test. Most
people expel about three-quarters of the air inhaled during this initial period of exhalation.
FEVI to FVC ratio test, which compares the amount of air expelled during the first second of exhalation (FEV1) to the total
amount of air exhaled during an FVC test.
Factors affecting Volume and Capacity
Age: The lung volumes increase steadily from birth to adulthood. The lungs Ethnicity: Previous studies demonstrated ethnic differences in the lung
mature at the age of 20–25 years, yet only minimal changes occur in the lung volumes/capacities. Such variations were largely attributed to
volumes over the following 10 years. After 35 years, aging is associated with anthropometric differences between different ethnic groups. For
gradual changes in the lung volumes and other pulmonary functions. These example, white Americans of European descent have larger trunk/leg
changes include diminished alveolar elastic recoil and depressed chest wall ratio, and consequently higher lung volumes, compared with black
compliance due to stiffening and increased outward recoil of the thoracic Americans of African descent.
cage. As a result of these changes, the inward recoil of the lung balances the
outward recoil of the chest at higher FRC as age progress. Gradual increase in Other factors: Lung volumes correlate well with the level of physical
FRC and RV with age results in simultaneous decrease in IC and VC. TLC activity, regular exercise, especially swimming and endurance training.
corrected for age remains almost constant throughout life. Alternatively, ascending to high altitude may decrease lung volumes
probably due to increased pulmonary blood flow, pulmonary edema or
VC = IRV + TV + ERV VC = IC + ERV premature small airways closure. Alterations in lung volumes associated
with high altitude are usually temporal and resolve after returning to the
TLC = VC + RV TLC = IC + FRC sea level.
FRC = ERV + RV IC = IRV+TV
Gender: Standard morphometric methods confirmed that males had larger
lung size, more respiratory bronchioles and wider airways diameters
compared with females with the same age and stature. Males tend to have
larger anthropometric measurements and are, therefore, more likely to have
increased static lung volumes and capacities.
Anthropometric measurements: Tall stature is typically associated with
higher static lung volumes and capacities. Increased body weight is
associated with lower lung volumes in obese subjects. Central obesity
preferentially depresses chest wall compliance leading to marked decrease in
FRC and ERV. In athletes, repeated muscular exercise increases muscle mass
and consequently body weight. In such condition, the static lung volumes and
capacities are expected to increase with weight. Increased total body fat
content, therefore, seems better than high BMI as an indicator of obesity as
well as predictor for decreased static lung volumes and capacities.
Normal vs Pathological Readings
The ratio of the two volumes (FEV1/FVC): This calculation allows the
identification of obstructive or restrictive ventilatory defects. FEV1/FVC <70%
where FEV1 is reduced more than FVC suggests an obstructive pathology.
FEV1/FVC >70% where FVC is reduced more so than FEV1 is seen in restrictive
pathology. Determining FEV1 measurement helps doctors understand the
severity of lung diseases. Typically, lower FEV1 scores show more severe
stages of lung disease.
contd

Common tests to diagnose obstructive and restrictive lung disease include:

• Forced vital capacity (FVC) testing. This involves inhalation and filling the
patient's lungs with as much air as they can, then having them exhale with
force. The FVC for patients with restrictive lung diseases is usually reduced.
An 80% or less FVC value of what's expected can indicate a restrictive
disease.
• Forced expiratory volume in 1 second (FEV1) testing. This testing measures
how much air is exhaled during the initial FVC testing.
• FVC to FEVI ratio testing. The FVC to FEV1 ratio measures how much air one
can exhale in one second forcefully, relative to the total amount one can
exhale. In obstructive lung diseases, this measure is reduced, but in
restrictive lung diseases, it's normal. In adults, normal means a 70% to 80%
FEV1/FVC ratio and in children normal means 85% or greater.
• X-rays. Chest X-rays create images of the patient's lung area and chest for
evaluation.
• Computed tomography (CT) scans. These scans generate more detailed
images of the patient's lung area and chest than X-rays, improving
diagnostic utility.
• Bronchoscopy. This entails using a flexible tube with an attached camera to
view the lungs and airways.
Obstructive Pulmonary Disease

Individuals with obstructive lung disease experience shortness of breath because they have
difficulty exhaling all of the air from their lungs. Because of airway narrowing inside their
lungs or due to damage to their lungs, exhaled air is more slowly expelled. After fully
exhaling, they'll still have an abnormally higher amount of air left lingering in their lungs.
Obstructive lung disease makes it more difficult to breathe, particularly during enhanced
exertion or activity. As the rate of breathing increases, patients have less time for exhaling
completely before the next inhalation.
Obstructive lung disease has a number of causes with some of the most common ones
being,
• Asthma
• COPD (Chronic Obstructive Pulmonary Disease), which includes chronic bronchitis and
emphysema
• Cystic fibrosis
• Bronchiectasis
The primary risk factor for this condition, according to the National Heart, Lung and Blood
Institute, is smoking. Exposure to environmental lung irritants such as dust, fumes,
chemicals, excessive secondhand smoke exposure etc can also lead to obstructive lung
disease. Scientists have also found genetics can play a role in developing the condition. For
instance, some individuals have an alpha-1 antitrypsin deficiency which is a symptom of
Obstructive Lung Disease. In the beginning, patients typically experience only mild
symptoms or have none at all. As the disease worsens, more severe symptoms appear.
contd

• In an obstructive lung disease, airway obstruction causes

an increase in resistance. During normal breathing, the
pressure volume relationship is no different from in a
normal lung. However, when breathing rapidly, greater
pressure is needed to overcome the resistance to flow,
and the volume of each breath gets smaller.
• In OLD, lungs appear larger; respiration ends prematurely
causing RV to increase; increased RV increases lung
capacity, however, this encroaches on vital capacity.
• IRV and ERV are decreased.
• FVC can decrease in a similar way in both obstructive lung
diseases and restrictive lung diseases. Often, doctors use
the FVC and FEV1 ratio to figure out the specific type of
lung disease. In the obstructed lung, FVC is smaller than
normal, but FEV1 is much smaller than normal. This is
because it is very difficult for a person with an obstructive
disease to exhale quickly due to the increase in airway
resistance. As a result, the FEV1/FVC ratio will be much
lower than normal, for example 40% as opposed to 80%.
• Ability to work and function normally might get reduced
with progression of disease.
Restrictive Lung Disease
Extrinsic restrictive lung disease is caused by complications with tissues or
Individuals with restrictive lung disease cannot fully fill their lungs with air. structures outside of the lungs, including neurological conditions. External
Their lungs are restricted from fully expanding. Restrictive lung disease most factors that cause an extrinsic restrictive lung disease are often associated
often results from a condition causing stiffness in the lungs themselves due with weakened muscles, damaged nerves, or the stiffening of the chest wall
to alteration in lung parenchyma. In other cases, stiffness of the chest wall, tissues.
weak muscles, or damaged nerves may cause the restriction in lung
Types of diseases and conditions involved in extrinsic restrictive lung disease
expansion.
can include: pleural effusions, or the buildup of excessive fluid between
Some conditions causing restrictive lung disease are: tissue layers surrounding the lungs, scoliosis (twisting of the spine),
neuromuscular disease or conditions, such as Lou Gehrig’s disease (ALS),
• Interstitial lung disease, such as idiopathic pulmonary fibrosis multiple sclerosis, and muscular dystrophy, obesity, myasthenia gravis
(intermittent muscle weakness), malignant tumors, rib damage, ascites, or
• Sarcoidosis, an autoimmune disease
abdominal swelling connected with liver scarring or cancer, heart failure etc
• Obesity, including obesity hypoventilation syndrome
• Scoliosis
• Neuromuscular disease, such as muscular dystrophy or amyotrophic
lateral sclerosis
Restrictive lung diseases are often divided into two groups, depending on
whether their cause is intrinsic or extrinsic.
Intrinsic restrictive lung disorders cause an internal abnormality, usually
leading to the stiffening, inflammation, and scarring of the lung tissues. Types
of diseases and conditions involved in intrinsic restrictive lung disease can
include: Pneumonia, tuberculosis, sarcoidosis, idiopathic pulmonary fibrosis
interstitial lung disease, lung cancers, fibrosis caused by radiation,
rheumatoid arthritis, infant and acute respiratory distress syndrome,
inflammatory bowel disease (IBD), systemic lupus.
contd

In a restrictive lung disease, the compliance of the lung is

reduced, which increases the stiffness of the lung and limits
expansion. In these cases, a greater pressure (P) than
normal is required to give the same increase in volume (V).
Restrictive lung diseases are characterized by reduced lung
volumes because inspiration is limited due to reduced
compliance; decreased TLC is observed; lungs appear much
smaller than normal.
The FVC of those with restrictive lung diseases is typically
decreased. A FVC value of less than or equal to 80 percent
of what is expected can be a sign of a restrictive disease.
FEVI to FVC ratio is often normal in those with restrictive
lung disease as both the FEV1 and FVC measurements
decrease proportionally. However, sometimes the FEV1/FVC
ratio can be higher than normal, for example 90% as
opposed to 80%. This is because it is easy for a person with
a restricted lung (e.g fibrosis) to breathe out quickly,
because of the high elastic recoil of the stiff lungs.
Measures of expiratory airflow are preserved and airway
resistance is normal.