Pulmonary physiology

291 Pages·2007·2.001 MB·English

by  Michael G Levitzky

a LANGE medical book
Pulmonary
Physiology
Seventh Edition
Michael G. Levitzky, PhD
Professor of Physiology, Anesthesiology, and Cardiopulmonary Science
Louisiana State University Health Sciences Center
New Orleans, Louisiana
Adjunct Professor of Pediatrics and Physiology
Tulane University Medical Center
New Orleans, Louisiana
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DOI: 10.1036/0071437754
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Contents
Preface ix
Chapter 1 Function & Structure of the Respiratory System 1
Objectives / 1
Functions of the Respiratory System / 2
Structure of the Respiratory System / 4
Key Concepts / 10
Suggested Readings / 10
Chapter 2 Mechanics of Breathing 11
Objectives / 11
Generation of a Pressure Gradient Between Atmosphere & Alveoli / 12
Pressure-Volume Relationships in the Respiratory System / 20
Interaction of Lung & Chest Wall: The Static Pressure-Volume Curve / 29
Airways Resistance / 32
The Work of Breathing / 49
Key Concepts / 50
Clinical Problems / 51
Suggested Readings / 52
Chapter 3 Alveolar Ventilation 54
Objectives / 54
The Lung Volumes / 54
Measurement of the Lung Volumes / 57
Anatomic Dead Space & Alveolar Ventilation / 65
Measurement of Alveolar Ventilation / 67
Alveolar Ventilation & Alveolar Oxygen & Carbon Dioxide Levels / 71
Regional Distribution of Alveolar Ventilation / 75
The Closing Volume / 79
The Effects of Aging / 81
Key Concepts / 82
Clinical Problems / 83
Suggested Readings / 84
Chapter 4 Blood Flow to the Lung 86
Objectives / 86
The Bronchial Circulation / 87
The Functional Anatomy of the Pulmonary Circulation / 89
Pulmonary Vascular Resistance / 92
The Regional Distribution of Pulmonary Blood Flow: The Zones
of the Lung / 99
Hypoxic Pulmonary Vasoconstriction / 105
iii
iv / CONTENTS
Pulmonary Edema / 108
Key Concepts / 111
Clinical Problems / 111
Suggested Readings / 112
Chapter 5 Ventilation-Perfusion Relationships 113
Objectives / 113
The Concept of Matching Ventilation & Perfusion / 113
Consequences of High & LowV˙/Q˙ / 114
Testing for Nonuniform Distribution of Inspired Gas & Pulmonary Blood
Flow / 116
RegionalV˙/Q˙ Differences & Their Consequences in the Lung / 125
Key Concepts / 128
Clinical Problems / 128
Suggested Readings / 129
Chapter 6 Diffusion of Gases 130
Objectives / 130
Fick’s Law for Diffusion / 130
Limitations of Gas Transfer / 133
Diffusion of Oxygen / 135
Diffusion of Carbon Dioxide / 137
Measurement of Diffusing Capacity / 137
Key Concepts / 140
Clinical Problems / 140
Suggested Readings / 141
Chapter 7 The Transport of Oxygen & Carbon Dioxide
in the Blood 142
Objectives / 142
Transport of Oxygen by the Blood / 142
Hemoglobin & the Physiologic Implications of the Oxyhemoglobin
Dissociation Curve / 145
Influences on the Oxyhemoglobin Dissociation Curve / 148
Transport of Carbon Dioxide by the Blood / 156
The Carbon Dioxide Dissociation Curve / 158
The Bohr & Haldane Effects Explained / 159
Key Concepts / 161
Clinical Problems / 161
Suggested Readings / 162
Chapter 8 The Regulation of Acid-Base Status 163
Objectives / 163
The Chemistry of Acids, Bases, & Buffers / 163
CONTENTS / v
Buffer Systems of the Human Body / 166
Acidosis & Alkalosis / 171
Respiratory & Renal Compensatory Mechanisms / 176
Clinical Interpretation of Blood Gases & Acid-Base Status / 178
The Causes of Hypoxia / 181
Key Concepts / 184
Clinical Problems / 185
Suggested Readings / 188
Chapter 9 The Control of Breathing 189
Objectives / 189
The Generation of Spontaneous Rhythmicity / 191
The Medullary Respiratory Center / 192
The Pontine Respiratory Group / 194
Spinal Pathways / 195
Reflex Mechanisms of Respiratory Control / 195
Influences of Higher Centers / 201
The Response to Carbon Dioxide / 202
The Response to Hydrogen Ions / 209
The Response to Hypoxia / 210
The Response to Exercise / 211
Key Concepts / 213
Clinical Problems / 214
Suggested Readings / 215
Chapter 10 Nonrespiratory Functions of the Lung 216
Objectives / 216
Pulmonary Defense Mechanisms / 216
Nonrespiratory Functions of the Pulmonary Circulation / 222
Metabolic Functions of the Lung / 224
Key Concepts / 227
Suggested Readings / 227
Chapter 11 The Respiratory System Under Stress 228
Objectives / 228
Exercise & the Respiratory System / 228
Altitude & Acclimatization / 234
Diving & the Respiratory System / 240
Key Concepts / 247
Clinical Problems / 247
Suggested Readings / 248
Clinical Problem Answers 250
vi / CONTENTS
Appendix 263
I. Symbols Used in Respiratory Physiology / 263
II. The Laws Governing the Behavior of Gases / 263
III. Frequently Used Equations / 264
IV. Pulmonary Function Test Decision Tree / 265
V. Table of Normal Respiratory and Circulatory Values / 266
VI. General Suggested Readings / 266
Index 267
Preface
The seventh edition of Pulmonary Physiology has been thoroughly updated. New
figures have been added to help students visualize concepts more clearly and learn
the material more effectively. New references have been added to the end of each
chapter. It has been more than 25 years since Pulmonary Physiology was first pub-
lished. The book is now older than many of the students reading it!
Perhaps the greatest pleasure associated with the first six editions has been receiv-
ing the many favorable comments and suggestions made by students, readers, and
colleagues, and I have used many of these suggestions in the preparation of this new
edition.
This book is intended to be used both as an introductory text for beginning stu-
dents and as a review for residents and fellows in such fields as internal medicine,
anesthesiology, pediatrics, and pulmonary medicine. Students who have studied
the text should be able to review for licensure and certification examinations by
concentrating on the figures, key concepts, tables, and appendices, which summa-
rize nearly all of the material in the book.
My goal in writing this book is to provide first-year medical students (as well as
respiratory therapy, nursing, nurse-anesthesia, and other students) with a solid
background in the aspects of pulmonary physiology essential for an understanding
of clinical medicine. My approach is to encourage self-sufficiency not only in
studying pulmonary physiology for the first time but also in understanding the
basic concepts of pulmonary physiology well enough to apply them with confi-
dence to future patients.
I believe that the ways to accomplish this are to inform the reader of the goals
of each chapter with clearly stated learning objectives, to give detailed and com-
plete explanations of physiologic mechanisms and demonstrate how they apply to
pathologic states, and to give the reader a means of self-testing by providing clini-
cal problems and pulmonary function test data to interpret.
The challenge is to write a book that students can read without difficulty in the
limited amount of time allocated to pulmonary physiology in the typical curriculum.
The material must be presented in a way that discourages memorization without real
comprehension, because only those students who understand the basic mechanisms
are able to apply them to new situations. The result of this approach should be a
book that covers the essentials of the respiratory system as concisely as possible yet
raises no questions in students’ minds without answering them. I hope that I have
achieved these goals in writing this book.
I would like to thank the many people whose comments have helped me revise
the various editions of the book including my colleagues in respiratory physiology
and pulmonary medicine, my colleagues at LSU Health Sciences Center and
Tulane University School of Medicine, as well as my students and readers. For this
edition I give special thanks to Drs. Andy Pellett of Louisiana State University
vii
Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
viii / PREFACE
Health Sciences Center and C. William Davis of the University of North Carolina
at Chapel Hill School of Medicine. I would also like to thank everyone who has
helped me prepare the manuscripts, illustrations, and proofs including my many
editors at McGraw-Hill. For this edition, I would especially like to thank Betsy
Giaimo, and my wife Elizabeth. Finally, very special thanks to Gail and Jim Miller
of Baton Rouge, Louisiana for taking us in after Hurricane Katrina and making us
feel at home for eight months.
This book is dedicated to Robert S. Alexander.
Michael G. Levitzky
COMMON ABBREVIATIONS
2,3-BPG 2,3-bisphosphoglycerate
DRG dorsal respiratory group
ERV expiratory reserve volume
FEF forced expiratory flow between 25 and 75 percent of the
25–75%
forced vital capacity
FEV forced expiratory volume in 1 second
1
FIO2 fractional concentration of inspired oxygen
FRC functional residual capacity
FVC forced vital capacity
HbA adult hemoglobin
Hbf fetal hemoglobin
[HCO(cid:1)]p plasma bicarbonate
3
IC inspiratory capacity
IRV inspiratory reserve volume
MPAP mean pulmonary artery pressure
MLAP mean left atrial pressure
MVV maximum voluntary ventilation
MW molecular weight
PBF pulmonary blood flow
PEEP positive end-expiratory pressure
PEF peak expiratory flow
PVR pulmonary vascular resistance
RV residual volume
SVR systemic vascular resistance
TLC total lung capacity
V˙A alveolar ventilation
V˙A/Q˙c orV˙/Q˙ ventilation-perfusion ratio
VC vital capacity
VD/VT ratio of dead space to tidal volume
VRG ventral respiratory group
VT tidal volume
V˙O2 oxygen consumption
V˙CO2 carbon dioxide production