a LANGE medical book
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`3 1858 026 413 116 f
`Review of
`_ Medical
`’ Physiology
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`i
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`,
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`'5
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`seventeenth edition
`
`William F. Ganong, MD
`DeLoris Lange Professor of Physiology Emeritus
`‘
`University of California
`‘
`San Francisco
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`ncluded in the list.
`we in parentheses
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`try and Physics,
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`APPLETON & LANGE
`Norwalk, Connecticut
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`Notice: The author and the publisher of this volume have taken care to
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`This advice is especiaJIy important when using new or infrequently used drugs.
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`Copyright © 1995 by Appleton & Lange
`A Simon & Schuster Company
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` nd ed. Lea & FBbiger,
`
`resuscitation. N Engl J
`
`.
`
`,5.
`
`5,.
`
`
`
`. i.
`
`:
`'
`
`..
`.
`
`.
`-"
`
`t
`
`n-induced injury in the
`ndrome. N Engl J Med
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`and proliferation of
`id1993;81:2844.
`\S: The immunopatho-
`:iciency virus infection.
`
`stats of septic shock. N
`
`E]: Neuroimmunology.
`
`'on emission tomogra-
`ibiochemistry. Science
`
`N Engl J Med 1990;
`
`:0 Proteins: Structure,
`at, 2nd ed. Academic
`
`SF: The C1 area of the
`oblongata: A critical
`f resting and reflex in-
`. Am J Hypertension
`
`:y, 1993.
`rosclerosis: A perspec-
`;362:801.
`ular Control. Oxford
`
`l. Oxford Univ Press.
`
`'rnphatics and lymph
`
`biology of the im-
`osuppressive ligands.
`
`physiology. FASEB J
`
`tors): The Molecular
`:rs, 1937.
`'1 Biochemistry of ni-
`‘ated forms. Science
`
`Edema. Raven Press,
`
`.uscle contractile ele-
`Ll'yperi‘en.i't'cm 1991;
`
`M: Regulatory func-
`lium. N Engl J Med
`
`I die immune system
`991;265:74.
`lies in diagnosis and
`
`eosinophils. N Engl J
`
`ardiology. N Engl J
`
`
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`Section VII.
`
`Respiration
`
`
`Pulmonary Function
`
`
`34
`
`INTRODUCTION
`
`Respiration, as the term is generally used, in-
`cludes 2 processes: external respiration, the ab-
`sorption of O2 and removal of-CUz-ffom the body as
`a whole; and internal respiration, the utilization of
`O2 and production of CO2 by cells and the gaseous
`exchanges between the cells and their fluid medium.
`Details of the utilization of O2 and the production of
`CO2 by cells are considered in Chapter 17. This
`chapter is concerned with the functions of the respi—
`ratory system in external respiration, ie, the
`processes responsible for the uptake of O2 and ex-
`cretion of CO2 in the lungs. Chapter 35 is concerned
`with the transport of O2 and CO2 to and from the tis-
`sues.
`
`The respiratory system is made up of a gas—ex-
`changing organ (the lungs) and a pump that venti-
`lates the lungs. The pump consists of the chest wall;
`the respiratory muscles, which increase and decrease
`the size of the thoracic cavity; the areas in the brain
`that control the muscles; and the tracts and nerves
`that connect the brain to the muscles. At rest, a nor-
`mal human breathes 12—15 times a minute. Five
`
`hundred milliliters of air per breath, or 6—8 Lr'rnin, is
`inspired and expired. This air mixes with the gas in
`the alveoli, and, by simple diffusion, O2 enters the
`blood in the pulmonary capillaries while CO2 enters
`the alveoli. In this manner, 250 ml. of O2 enters the
`body per rriinute and 200 mL of CO2 is excreted.
`Traces of other gases such as methane from the
`intestines are also found in expired air. Alcohol and
`acetone are expired when present in appreciable
`quantities in the body. Indeed, over 250 different
`Volatile substances have been identified in human
`breath .
`
`PROPERTIES OF GASES
`
`Partial Pressures
`Unlike liquids, gases expand to fill the volume
`available to them, and the volume occupied by a
`given number of gas molecules at a given tempera-
`
`591
`
`ture and pressure is (ideally) the same regardless of
`the composition of the gas.
`
`P = "RT (from equation of
`V
`state of ideal gas)
`
`where
`
`P = Pressure
`n = Number of moles
`H = Gas constant
`T = Absolute temperature
`V = Volume
`
`Therefore. the pressure exerted by any one gas in
`a mixture of gases (its partial pressure) is equal to
`the total pressure times the fraction of the total
`amount of gas it represents.
`The composition of dry air is 20.98% 02. 0.04%
`C02, 78.06% N2, and 0.92% outer inert constituents
`such as argon and helium. The barometric pressure
`(PB) at sea level is 760 mm Hg (one atmosphere).
`The partial pressure (indicated by the symbol P) of
`02 in dry air is therefore 0.21 x 760, or 160 mm Hg
`at sea level. The partial pressure of N2 and the other
`inert gases is 0.79 x 760, or 600 mm Hg; and the
`PCO2 is 0.0004 x 760, or 0.3 mm Hg. The water va-
`por in the air in most climates reduces these percent-
`ages, and therefore the partial pressures, to a slight
`degree. Air equilibrated with water is saturated with
`water vapor, and inspired air is saturated by the time
`it reaches the lungs. The PHEO at body temperature
`(37 °C) is 47 mm Hg. Therefore, the partial pres-
`sures at sea level of the other gases in the air reach—
`ing the lungs are P02, 149 mm Hg; PCOI, 0.3 mm Hg;
`and PN: (including the other inert gases), 564 mm
`Hg.
`Gas diffuses from areas of high pressure to areas
`of low pressure, the rate of diffusion depending upon
`the concentration gradient and the nature of the bar-
`rier between the 2 areas. When a mixture of gases is
`in contact with and permitted to equilibrate with a
`liquid, each gas inTl'lE’mixture dissolves in the liquid
`to an extent determined by its partial pressure and its
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`592 / CHAPTER 34
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`'
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`‘
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`Table 34-4. Standard conditions to which measurements
`involving gas volumes are corrected.
`
`
`i's'rpa
`7
`_
`0- =0. 760 mm Hgdry; (standard temperature-and
`présSUremiryl,
`4
`.-
`
`" Bodyjteinperatureand pressure, saturated with
`EBTPS,
`
`
`
`
`.
`MPG“ statutes:temperatureand-prasswedry '
`°Ares .fi'
`Atheism temperature and pressure, saturated '
`., withwater vapor
`, '
`-
`
`
`_
`
`,-
`
`__
`
`
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`solubility in the fluid. The partial pressure of a gas in
`a liquid is that pressure which in the gaseous phase in
`equilibrium with the liquid would produce the con-
`centration of gas molecules found in the liquid.
`
`Methods of Quantitating
`Heepiratory Phenomena
`Respiratory excursions can be recorded by devices
`that measure chest expansion, or by recording
`spirorneters (see Fig 17—1), which also permit mea-
`surement of gas intake and output. Since gas volumes
`vary with temperature and pressure and since the
`
`amount of water vapor in them varies, it is important I;
`to correct respiratory measurements involving V0]-
`ume to a stated set of standard conditions. The 4
`most commonly used standards and their abbreviat
`tions are shOWn in Table 34—1. Modern techniques
`for gas analysis make possible rapid, reliable mea-
`surements of the composition of gas mixtures and the,
`gas content of body fluids. For example, 02 and C02
`electrodes, small probes sensitive to 02 or C02, can
`be inserted into the airway or into blood vessels or
`tissues and the P02 and PC02 recorded continuouSIy,
`Chronic assessment of oxygenation is carried out
`noninvasively with a pulse oximeter, which is usu-
`ally attached to the ear. Absorption of light passing
`through tissue is mathematically related to the
`amount of oxyhemoglobin in the tissue, and the pulse
`oximeter eliminates the constant absorption due to
`tissue and other components and measures only the
`absorption of pulsatile arterial blood. C02, carbon
`monoxide (CO), and many anesthetic gases can be
`measured rapidly by infrared absorption spec-
`troscopy. Gases can also be measured by gas chro-
`matography or mass Spectrometry.
`
`
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`Vasomotor nerves
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`Lymphatics
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` Bronchomotor
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`
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`nerve
`
`Pulmonary
`vein
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`Vasomotor
`nerves
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