《呼吸科呼吸系统》PPT课件.ppt

Unit5 Respiration DefinitionofRespirationTheprocessthathumanbodyexchangesgaseswiththeatmosphere orTheprocessoftakingupoxygenandremovingcarbondioxidefromcellsinthebody 2 17 2020 1 Dyspnea Apnea Dyspneameansthatthereisairhunger Apneameansnobreathing Whenyoucan tbreathe nothingelsemattersSloganoftheAmericanLungAssociation 2 17 2020 3 MainTopics 5 1 PulmonaryventilationTheventilatorypumpMechanicsofventilationElasticandnon elasticresistancesStaticlungvolumeDynamiclungventilation5 2 GasexchangeGasdiffusionFactorsthataffectgasexchangeVentilation perfusionratio VA Q 5 3 GastransportinthebloodOxygen carbondioxide carbonmonoxidepoisoning5 4 ThecontrolofventilationRespiratorycenterandthebasicrespiratorypatternVoluntarycontrolChemosensoryreflexesMechanicalreflexes 2 17 2020 4 2020 2 17 WhoamI Name 詹仁知E mail zhan0001 Location 6 338 5 网上学习材料 复旦大学上海医学院生理学精品课程 2 17 2020 6 ConductingZoneandRespiratoryZone Type1alveolarcellsThesecellsarederivedfromtypeIIalveolarcellsandprovideathinlayerofcytoplasmwhichcoversabout80 ofthegasexchangezone TypeIIalveolarcellsThesecellsallowtheformationofsurfactantandotherenzymes TypeIIIalveolarcellsThesecellsarethemainlungdefencesystem theyarethealveolarmacrophages MainFunctionalEventsofRespiration 2 17 2020 9 Terminology Pulmonaryventilation 肺通气 Theinflowandoutflowofairbetweentheatmosphereandthelungalveoli Gasexchange 肺换气 Diffusionofoxygenandcarbondioxidebetweenthealveoliandthebloodinsidethepulmonarycapillaries Gastransportintheblood 气体在血液中的运输 Transportsofoxygenandcarbondioxideinthebloodandbodyfluidtoandfromthetissuecells Tissuegasexchange 组织换气 Theexchangeofoxygenandcarbondioxidebetweenbloodandcellsindifferenttissues 2 17 2020 10 Terminology Continued ExternalRespiration 外呼吸 Exchangeofgasesbetweentheatmosphereandthebloodinpulmonarycapillaries Itconsistsofpulmonaryventilationandgasexchange InternalRespiration 内呼吸 Theexchangeofoxygenandcarbondioxidebetweenbloodandcellsindifferenttissues Itconsistsoftissuegasexchangeandbiologicaloxidation 2 17 2020 11 Summary 1 Breathingisessentialtolife 2 Theprimaryfunctionofrespirationistoprovideoxygenformetabolicneedsandtoremovecarbondioxidefromcellsinthebody 3 Themainfunctionaleventsofrespirationarepulmonaryventilation gasexchange gastransportinthebloodandtissuegasexchange 2 17 2020 12 5 1 PulmonaryVentilation DefinitionPulmonaryventilationreferstotheinflowandoutflowofairbetweentheatmosphereandthelungalveoli 2 17 2020 13 TwoPhasesoftheBreathingCycle Inspirationorinhalation 吸气 InspirationisthemovementofairintothelungsExpirationorexhalation 呼气 Expirationisthemovementofairoutofthelungs 2 17 2020 14 2020 2 17 15 NormalQuietBreathingvs ForcedBreathing 平静呼吸vs 用力呼吸 AbdominalBreathingvs ThoracicBreathing 腹式呼吸vs 胸式呼吸 2 17 2020 16 LungVentilation 肺通气 DrivingforceAgainstResistance 2 17 2020 17 5 1 1 TheVentilatoryPump Chestwall 胸壁 Spine ribsandsternumRespiratorymusclesThediaphragm 膈肌 ThemaininspiratorymuscleTheintercostalmuscles 肋间肌 Theexternalintercostalmuscles inspiratorymuscles Theinternalintercostalmuslces expiratorymuscles Pleuralcavity 胸膜腔 2 17 2020 18 ThePleuralCavity 胸膜腔 Thepleuralcavityisthepotentialspacebetweenthelungsandthechestwall containingasmallamountofpleuralfluid 2 17 2020 19 RespiratoryMuscles 呼吸肌 1 InspiratoryDiaphragm 膈肌 Externalintercostalmuscles 肋间外肌 2 Accessory 辅助 Scalene 斜角肌 Sternocleidomastoidmuscles 胸锁乳突肌 3 ExpiratoryAbdominalmusclesInternalintercostalmuscles 肋间内肌 2 17 2020 20 TheDiaphragm 膈肌 Themostimportantmuscleforinspiration Contractionofthediaphragmpushestheabdominalcontents 腹腔内容物 downwardandliftstheribs 肋骨 upwardandoutward increasingthevolumeofthethoraciccavityin3directions 2 17 2020 21 PressuresinDifferentCompartments Barometricpressure 大气压 Theatmospheretheairwebreatheandlivein expertsapressureknownasbarometricpressure PB Pleuralpressureorintrapleuralpressure 胸膜腔内压 Thepressureinthepleuralspacebetweenthelungandthechestwallispleuralpressure Ppl Adecreaseinpleuralpressurecausesthelungstoexpand Thepleuralpressurestartstodecreaseinthebeginningofuntiltheendofinspiration Alveolarpressureorintrapulmonarypressure 肺内压 Alveolarpressureisthepressureinsidethealveoli itdeterminesinwardoroutflowofair Transpulmonarypressure 跨肺压 Transpulmonarypressureisthepressuredifferenceacrossthelungwall PA Ppl 2 17 2020 22 TheNegative subatmospheric PleuralPressure Innormalquietbreathing thepleuralpressureisnegative lowerthantheatmospphericpressure Elasticrecoil 弹性回缩 ofthelungsandchestwallresultsinnegativepleuralpressure Thepleuralpressurechangesaccordingtobreathingcyclewiththemaximalnegativepleuralpressurereachesjusttheendofinspirationduetothebiggestelasticrecoilofthelungs Forcedexpirationcanresultinapositivepleuralpressure 2 17 2020 23 Windblows Whenpressuredifferencebetweentwoadjacentcompartmentsexists 2 17 2020 24 FromPressureDifferencestoAirflow Thedifferencebetweenalveolarpressureandbarometricpressureisthedirectdrivingforceforventilation Inspiratorymusclecontractionistheprimarydrivingforceforventilation Negativealveolarpressure lowerthantheatmosphericpressure resultsininspirationwhereaspositivealveolarpressurecausesexpiration Foranygivencycleofbreathing thereisatimepointwherealveolarandthebarometricpressuresareequal theendofispirationorjustbeforeexpiration 2 17 2020 25 1 Thepleaural orintrapleaural pressurereachesitsmaximumnegativelevelattheendofinspiration 2 Attheendofispirationorjustbeforeexpiration thealveolarandthebarometricpressuresareequal 3 Flowrateincreases ordecreases inparallelwithalveolarpressure ConclusionsDrawnfromtheLeftFigure 2 17 2020 26 Boyle sLaw 2 17 2020 27 InspiratoryMusclesContract ThoracicCavityExpands PleuralPressureBecomesmoreNegative TranspulmonaryPressureIncreases AlveolarPressureBecomesSubatmospheric AirFlowsintotheLungsuntilAlveolarPressureEqualsAtmosphericPressure P1XV1 P2XV2 Boyle sLaw SequentialEventsOccurduringInspiration LungstendtoInflate 2 17 2020 28 SequentialEventsOccurduringExpiration RelaxationofDiaphragm ThoracicCavityShrinks NegativePleuralPressureDecreases TranspulmonaryPressureBecomesSmall AlveolarPressureRisesabovetheAtmosphericPressure LungVolumeTendstoDecrease AirFlowsouttheLungsuntilAlveolarPressureEqualsAtmosphericPressure P1XV1 P2XV2 Boyle sLaw 2 17 2020 29 TheSignificanceofaNegativePleuralPressure Keepsthelungstobeinflatedasitisdemonstratedinpneumothorax 气胸 Promotesthereturnsofvenousbloodandlymphaticfluid 淋巴液 2 17 2020 30 Pneumothorax 气胸 Aconditioninwhichairhasenteredandexpandedthenormallyclosedpleuralspace drivingpleuralpressureuptowardatmosphericpressure andresultinginpartialorcompletecollapseofthelung 2 17 2020 31 ConsequencesofPneumothorax Hypoxia 缺氧 duetoshunt bloodpassesthroughthosecollapsedalveoli Decreaseinvenousbloodreturnduetocompressionofvenacava resultinginlowercardiacoutputandconsequentlyhypotension circulatorycollapse 2 17 2020 32 CasesofPneumothorax Case1 Apatientwhounderwentstomachsurgeryunderepiduralanesthesiahassymptomsofanxiety intensifiedabdomenbreathingandlowbloodpressurewithdecreasedpulsepressure Case2 ApatientwithhistoryofemphysemapresentedtoERwithdifficultbreathingandcyanosis ChestX rayshowednosignsofcollapsedlung 2 17 2020 33 SummaryonDrivingForcesforVentilation Thenegativepleuralpressureresultsfromtheelasticrecoilofthelungsandthechestwall keepingthelungstobeinflated Chestwallmovementcausedbythecontractionofinspiratorymusclesmainlythediaphragmistheprimarydrivingforceforventilation leadingtochangesinalveolarpressure Thepressuredifferencebetweenthealveoliandtheatmosphereisthedirectdrivingforceforventilation leadingtoinhalationorexhalation 2 17 2020 34 InspiratoryMusclesContract ThoracicCavityExpands PleuralPressureBecomesmoreNegative TranspulmonaryPressureIncreases AlveolarPressureBecomesSubatmospheric AirFlowsintotheLungsuntilAlveolarPressureEqualsAtmosphericPressure P1XV1 P2XV2 Boyle sLaw SequentialEventsOccurduringInspiration LungstendtoInflate 2 17 2020 35 SequentialEventsOccurduringExpiration RelaxationofDiaphragm ThoracicCavityShrinks NegativePleuralPressureDecreases TranspulmonaryPressureBecomesSmall AlveolarPressureRisesabovetheAtmosphericPressure LungVolumeTendstoDecrease AirFlowsouttheLungsuntilAlveolarPressureEqualsAtmosphericPressure P1XV1 P2XV2 Boyle sLaw 2 17 2020 36 SequentialEventsOccurduringExpiration RelaxationofDiaphragm ThoracicCavityShrinks NegativePleuralPressureDecreases TranspulmonaryPressureBecomesSmall AlveolarPressureRisesabovetheAtmosphericPressure LungVolumeTendstoDecrease AirFlowsouttheLungsuntilAlveolarPressureEqualsAtmosphericPressure P1XV1 P2XV2 Boyle sLaw 2 17 2020 37 5 1 2 MechanicalPropertiesoftheLungsandChestWall Howthelungsinflateanddeflatenotonlydependontranspulmonarypressurebutalsoelasticpropertiesoflungsandchestwall Threeterms elasticrecoil stiffnessanddistensibility areusedtodescribetheelasticpropertiesofthelungsandchestwall 2 17 2020 38 Stiffness DistensibilityandElasticRecoil Stiffness 硬度 isdefinedasresistancetobestretchedorinflated Distensibility 可扩张性 isthetermappliedtotheeasewithwhichthelungscanbestretchedorinflated Elasticrecoil 弹性回缩 isdefinedastheabilityofastretchedorinflatedlungtoreturntoitsrestingvolume FRC Distensibiltyandelasticrecoilareinverselyrelatedtoeachother 2 17 2020 39 LungCompliance CL Lungcompliance CL isameasureofdistensibility CLisdefinedbychangeinvolumeperchangeinpressure ItcanbewrittenasCL volume pressure Where volumeequalschangeinvolumeand pressureequalschangeinpressure CListheslopeofthepressure volumecurve 2 17 2020 40 MeasurementofCLinHumans 2 17 2020 41 FactorsthatAffectCL ElasticrecoilInverselyrelatedLungvolumeProportionallyrelatedSurfacetension willbeanalyzedlater Inverselyrelated 2020 2 17 42 PathologicalConditionsThatAreAssociatedwithReducedCL Damageofelastinfiberse g COPDFibrosisPulmonaryhypertension congestionIncreasesstiffnessofthelungsAlveolaratelectasise g afterprolongedperiodofventilationReducedsurfactant increasedsurfacetension e g artificialventilation prematurity 2 17 2020 43 ObstructiveandRestrictiveDisordersAffectCLdifferently 2020 2 17 44 Obstructivedisease Restrictivedisease Restrictivelungdiseasesareassociatedwithincreasedcollagenfibers 胶原纤维 Obstructivelungdiseases emphysemaandCOPD areassociatedwithdamageofelastinfibers 弹性纤维 Smokingdamageselastinfibers causingemphysema 肺气肿 ElasticRecoilofChestWall Thechestwallhaselasticproperty Theoutwardofelasticrecoilofthechestwallaidslongexpansionwhereastheinwardofelasticrecoiloflungpullsinthechestwall Atabout67 oftotallungcapacity chestwallisinitsnaturalposition Iflungvolumeislessthan67 ofTLC thechestwalltendstorecoiloutward Iflungvolumeismorethan67 ofTLC ittendstorecoilinward 2 17 2020 45 ChangesinChestWallComplianceAreLessCommon Pathologicsituationspreventingthenormalmovementoftheribcage suchasdistortionofthespinalcolumn Pathologic cancer orphysiologic pregnancy reasonsincreasingtheintraabdominalpressure Stiffchest suchasbrokenribs 2 17 2020 46 WhatisSurfaceTension Surfacetensionisapropertyofthesurfaceofaliquid Itiswhatcausesthesurfaceportionofliquidtobeattractedtoanothersurface suchasthatofanotherportionofliquid Inalveoli thesurfaceofalveolarmembraneismoistandisincontactwithair producingalargeair liquidinterface Thesurfacetensionpreventstheexpansionofalveoliandrisesresistanceforventilation 2 17 2020 47 HowDoesSurfaceTensionAffectLungCompliance Theexperimentwasdoneinanisolatedlung Thelungwasinflatedanddeflatedinastepwisefashion firstwithairandthenwithsaline Withair filledlungs thegas liquidinterfacecreatessurfacetension therelationisdifferentforinspirationandexpiration Inthesaline filledlung air liquidinterfaceiseliminatedasitssurface 2 17 2020 48 WorksareNeededtoExpandtheLungs Surfacetensioncausesadecreaseinlungcompliance Twothirdsoftheworkrequiredtoinflatethelungisspenttoovercomesurfacetension grayarea ToexpandthelungFirsttoovercomethesurfacetension grayarea Thentoovercometheelasticrecoil bluearea 2 17 2020 49 SurfaceTensionAffectsAlveolarStability Pindicatesinternalpressurethatisneededtokeepanalveolustobeinflated Tindicatessurfacetension Ristheradiusofanalveolus 2 17 2020 50 拉普拉斯 1749 1827 PulmonarySurfactant Source Chemistry Pulmonarysurfactantisalipoproteinrichinphospholipid 磷脂 Theprincipalagentresponsibleforitssurfacetension reducingpropertiesisdipalmitoylphosphatidylcholine DPPC 二磷脂酰卵磷脂 AlveolartypeIIcellssynthesizeandstorelungsurfactant Infantsbornbeforegestationalweek26producelittlesurfactant 2 17 2020 51 PhysiologicalFunctionsofSurfactant IncreaseslungcomplianceandconsequentlyreducesventilatoryresistanceStabilizesalveoliKeepsthealveoli dry 2 17 2020 52 2020 2 17 53 InfantRespiratoryDistressSyndrome SummaryonLungCompliance Lungcompliance CL isdefinedaschangeinvolumeperchangeinpressure CLisameasureoflungdistensibility itisinverselyrelatedtostiffness Abnormallylowlungcomplianceindicatesastifflung whichmeansmoreworkisneededtoinflatethelungtobringinanormaltidalvolume Abnormallyhighlungcomplianceresultsinincreasedstaticvolumes RV VC FRCetc 2 17 2020 54 SummaryonSurfaceTension Thesurfacetensionisaforcethatpreventsalveolitobeopenedandrisesresistanceforventilation 2 17 2020 55 SummaryonSurfactant ProductionPulmonarysurfactantisalipoproteinrichinphospholipid mainlydipalmitoylphosphatidylcholine DPPC andismanufacturedbythealveolarepithelialtypeIIcells FunctionSurfactantreducessurfacetensionwithinthealveoliwhichhelpstoincreasethecomplianceofthelungandthuslowerrespiratoryresistanceItimprovesalveolarstabilityItkeepsalveolidrybyopposingwatermovementfromthepulmonaryinterstitium 5 1 3 VentilatoryResistance Elasticresistance 70 oftotal Itisastaticresistancethatpreventsthelungstobeinflated Itresultsfromelasticrecoil 30 andsurfacetension 70 Non elasticresistance 30 oftotal Itisadynamicresistance resultingfromthemovementofair Itconsistsofinertialresistance 惯性阻力 viscousresistance 粘滞阻力 andairwayresistance 80 ofnon elasticresistance 2 17 2020 57 SurfaceTensionandElasticRecoilMakeUpElasticResistance Toexpandthelung1 Firsttoovercomethesurfacetension grayarea 2 Thentoovercometheelasticrecoil bluearea Twothirdsoftheworkrequiredtoinflatethelungisspenttoovercomesurfacetension Onethirdoftheworkrequiredtoinflatethelungisspenttoovercometheelasticrecoil Elasticresistanceconsistsoftwocomponents surfacetensionandelasticrecoil 2 17 2020 58 AirwayResistance Itmakesthelargestproportion 80 ofnon elasticresistance IcanbeestimatedbyRaw P PA PB V gasflow 2 17 2020 59 FactorsthatAffectAirwayResistance ThediameteroftheairwaysThenumberofairwaysThelungvolume 2 17 2020 60 WhereDoestheAirwayConstitutetheSiteofLargestAirwayResistance Themedium sizedairways 2mm OrThesmallairways 2mm 2 17 2020 61 Themedium sizedbronchi 2mm actuallyconstitutethesideofhighestresistancealongthebronchialtree Althoughthesmallradiiofbronchioles 2mm mightpredictthattheywouldhavethelargestresistance theydonotbecauseoftheirparallelarrangement Earlychangesinresistanceinthesmallairwaysmaybe silent andgoundetectedbecauseoftheirsmalloverallcontributiontoresistance 2 17 2020 62 NeurohumoralControloftheAirways Michoudetal 2 17 2020 63 TheSmoothMuscleToneofAirwaysisControlledbyNerves SympatheticadrenergicfibersBronchialdilation inhibitionofglandsecretion ParasympatheticcholinergicpostganglionicfibersBronchialconstriction increasedmucussecretionNon adrenergicnon cholinergicneuronalfibersBronchcoconstrictoryeffects tachykinins substancePorneurokininetc Bronchodilatatorypathway nitricoxideandvasoactiveintestinalpeptide 2 17 2020 64 2 adrenergicReceptorsandcholinergicMuscarinicReceptors Stimulationofsympatheticadrenergicfiberscausesdilationofbronchialandbronchiolarairwaysvia 2adrenergicreceptoractivationandinhibitionofglandsecretion 2 adrenergicagonistsareusedfortreatmentofasthma Stimulationofparasympatheticcholinergicpostganglionicfiberscausesbronchialconstrictionaswellasincreasedmucussecretionviamuscarinicreceptor M2 M3 activation Mreceptorantagonistsareusedfortreatmentofasthma 2 17 2020 65 LungVolumeinverselyRelatestoAirwayResistance 2 17 2020 66 SummaryonVentilatoryResistances Elasticresistance 70 oftotalventilatoryresistance Itisastaticresistance Itresultsfromelasticrecoil 30 andsurfacetension 70 Non elasticresistance 30 oftotal Itisadynamicresistance Itconsistsofinertialresistance viscousresistanceandairwayresistanceTheairwayresistanceaccounts80 ofnon elasticresistance 2 17 2020 67 Respiratoryresistance elasticresistance 70 thoracicelasticresistance lungelasticresistance elasticrecoil 1 3 surfacetension 2 3 inertialresistance viscousresistance airwayresistance 80 90 non elasticresistance 30 SummaryonRespiratoryResistance 2 17 2020 68 5 1 4 StaticandDynamicLungVolumes Lungvolumesdeterminedbyanatomicalsizesofthepulmonarytract 2 17 2020 69 2020 2 17 70 2020 2 17 70 2020 2 17 70 StaticLungVolume 静态肺容积 Spirometry 肺量计 adevicethatisusedtomeasurethevolumeofairthatisbreathedinoroutofthelungs Notalllungvolumescanbemeasureddirectlybyspirometry e g RVanditsrelatedFRCandTLC 2020 2 17 71 2020 2 17 71 2020 2 17 71 2020 2 17 71 Volume vs Capacity Lungvolume 肺容积 andlungcapacity 肺容量 areusedindifferentterms Volumeisusedwhenonlyonevolumeisinvolved andcapacityisusedwhenavolumecanbebrokendownintotwoormore Forexample thefunctionalresidualcapacity FRC isthesumofERVandRV ImportantPulmonaryVolumes Thetidalvolume 潮气量 VT isthevolumeofairinspiredorexpiredwitheachnormalbreath Theinspiratoryreservevolume 补吸气量或吸气储备量 IRV istheextravolumeofairthatcanbeinspiredoverandabovethenormaltidalvolume Theexpiratoryreservevolume 呼气储备量或 补呼气量 ERV isthemaximumextravolumeofairthatcanbeexpiredbyforcefulexpirationaftertheendofnormaltidalexpiration Theresidualvolume 余气量或残气量 RV isthevolumeofairremaininginthelungsaftermaximumexpiration 2020 2 17 72 ImportantLungCapacities Theinspiratorycapacity 吸气容量或深吸气量 IC isthevolumeofgasthatcanbetakenintothelungsinafullinhalation startingfromtherestinginspiratoryposition ICisequaltothetidalvolumeplustheinspiratoryreservevolume IRV Thefunctionalresidualcapacity 功能残气量 FRC isthevolumeofairremaininginthelungsafteranormalexpiration FRC REV RV Thevitalcapacity VC isthemaximumamountofairapersoncanexpelfromthelungsafterfillingthelungstothemaximumextentandthenexpiringtothemaximumextent VC IRV VT ERV Thetot