Review of
`
` Ganong$
`
`23rd Edition
`
`Kim Barrett
`
`Heddwen Brooks
`
`Scott Boitano
`
`Susan Barman
`
`25L
`
`1
`
`I.
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`|PR2017-01622, Ex. 1169, p. 1 of 5
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`WATSON LABORATORIES, INC. ,
`WATSON LABORATORIES, INC. ,
`IPR2017-01622, Ex. 1169, p. 1 of 5
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`

`

`a LANGE medical book
`
`Ganong’s
`Review of
`Medical Physiology
`
`Twenty-Third Edition
`
`Kim E. Barrett, PhD
`Professor
`Department of Medicine
`Dean of Graduate Studies
`University of California, San Diego
`La Jolla, California
`
`Susan M. Barman, PhD
`Professor
`Department of Pharmacology/Toxicology
`Michigan State University
`East Lansing, Michigan
`
`Scott Boitano, PhD
`Associate Professor, Physiology
`Arizona Respiratory Center
`Bio5 Collaborative Research Institute
`University of Arizona
`Tucson, Arizona
`
`Heddwen L. Brooks, PhD
`Associate Professor
`Department of Physiology
`College of Medicine
`University of Arizona
`Tucson, Arizona
`
`New York Chicago San Francisco Lisbon London Madrid Mexico City
`Milan New Delhi
`San Juan Seoul
`Singapore
`Sydney Toronto
`
`WATSON LABORATORIES, INC. , IPR2017-01622, Ex. 1169, p. 2 of 5
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`

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`Copyright © 2010 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this
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`SECTION VII RESPIRATORY PHYSIOLOGY
`
`C H A P T E R
`
`35
`
`Pulmonary Function
`
`O B J E C T I V E S
`
`After studying this chapter, you should be able to:
`■ Define partial pressure and calculate the partial pressure of each of the important
`gases in the atmosphere at sea level.
`■ List the passages through which air passes from the exterior to the alveoli, and
`describe the cells that line each of them.
`■ List the major muscles involved in respiration, and state the role of each.
`■ Define the basic measures of lung volume and give approximate values for each in
`a normal adult.
`■ Define compliance, and give examples of diseases in which it is abnormal.
`■ Describe the chemical composition and function of surfactant.
`■ List the factors that determine alveolar ventilation.
`■ Define diffusion capacity, and compare the diffusion of O2 with that of CO2 in the
`lungs.
`■ Compare the pulmonary and systemic circulations, listing the main differences
`between them.
`■ Describe basic lung defense and metabolic functions.
`
`INTRODUCTION
`Respiration, as the term is generally used, includes two pro-
`cesses: external respiration, the absorption of O2 and
`removal of CO2 from the body as a whole; and internal respi-
`ration, the utilization of O2 and production of CO2 by cells
`and the gaseous exchanges between the cells and their fluid
`medium. Aspects of external respiratory physiology are pre-
`sented throughout this section. In this chapter, the processes
`
`responsible for the uptake of O2 and excretion of CO2 in the
`lungs are explored. The next chapter is concerned with the
`transport of O2 and CO2 to and from the tissues. The final
`chapter in this section examines some key factors that regu-
`late respiration. Throughout each chapter, clinical implica-
`tions of specific physiology will be presented.
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`588
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`SECTION VII Respiratory Physiology
`
`PROPERTIES OF GASES
`The pressure of a gas is proportional to its temperature and the
`number of moles per volume:
`nRT
`---------- (from equation of state of ideal gas)
`V
`
`P
`
`=
`
`where
`P = Pressure
`n = Number of moles
`R = Gas constant
`T = Absolute temperature
`V = Volume
`
`PARTIAL PRESSURES
`
`Unlike liquids, gases expand to fill the volume available to
`them, and the volume occupied by a given number of gas mol-
`ecules at a given temperature and pressure is (ideally) the same
`regardless of the composition of the gas. Therefore, the pres-
`sure 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% O2, 0.04% CO2,
`78.06% N2, and 0.92% other inert constituents such as argon
`and helium. The barometric pressure (PB) at sea level is 760
`mm Hg (1 atmosphere). The partial pressure (indicated by the
`symbol P) of O2 in dry air is therefore 0.21 × 760, or 160 mm
`Hg at sea level. The PN2 and the other inert gases is 0.79 × 760,
`or 600 mm Hg; and the PCO2 is 0.0004 × 760, or 0.3 mm Hg.
`The water vapor in the air in most climates reduces these per-
`centages, 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
`PH2O at body temperature (37 °C) is 47 mm Hg. Therefore, the
`partial pressures at sea level of the other gases in the air reach-
`ing the lungs are PO2, 149 mm Hg; PCO2, 0.3 mm Hg; and PN2
`(including the other inert gases), 564 mm Hg.
`Gas diffuses from areas of high pressure to areas of low
`pressure, with the rate of diffusion depending on the concen-
`tration gradient and the nature of the barrier between the two
`areas. When a mixture of gases is in contact with and permit-
`ted to equilibrate with a liquid, each gas in the mixture dis-
`solves in the liquid to an extent determined by its partial
`pressure and its solubility in the fluid. The partial pressure of
`a gas in a liquid is the pressure that, in the gaseous phase in
`equilibrium with the liquid, would produce the concentration
`of gas molecules found in the liquid.
`
`METHODS OF QUANTITATING
`RESPIRATORY PHENOMENA
`
`TABLE 35–1 Standard conditions to which
`measurements involving gas volumes are corrected.
`
`STPD
`
`0 °C, 760 mm Hg, dry (standard temperature and pressure,
`dry)
`
`BTPS
`
`Body temperature and pressure, saturated with water vapor
`
`ATPD
`
`Ambient temperature and pressure, dry
`
`ATPS
`
`Ambient temperature and pressure, saturated with water
`vapor
`
`pressure and since the amount of water vapor in them varies,
`these devices have the ability to correct respiratory measure-
`ments involving volume to a stated set of standard conditions.
`The four most commonly used standards and their abbrevia-
`tions are shown in Table 35–1. It should be noted that correct
`measurements are highly dependent on the ability for the
`practitioner to properly encourage the patient to fully utilize
`the device. Modern techniques for gas analysis make possible
`rapid, reliable measurements of the composition of gas mix-
`tures and the gas content of body fluids. For example, O2 and
`CO2 electrodes, small probes sensitive to O2 or CO2, can be in-
`serted into the airway or into blood vessels or tissues and the
`PO2 and PCO2 recorded continuously. Chronic assessment of
`oxygenation is carried out noninvasively with a pulse oxime-
`ter, which is usually attached to the ear.
`
`ANATOMY OF THE LUNGS
`THE RESPIRATORY SYSTEM
`
`The respiratory system is made up of a gas-exchanging organ
`(the lungs) and a “pump” that ventilates the lungs. The pump
`consists of the chest wall; the respiratory muscles, which in-
`crease 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 normal human
`breathes 12 to 15 times a minute. About 500 mL of air per
`breath, or 6 to 8 L/min, 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 al-
`veoli. In this manner, 250 mL of O2 enters the body per minute
`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.
`
`AIR PASSAGES
`
`Modern spirometers permit direct measurement of gas intake
`and output. Since gas volumes vary with temperature and
`
`After passing through the nasal passages and pharynx, where it
`is warmed and takes up water vapor, the inspired air passes
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