8/15/2022
Goal of Respiratory Therapy
• Get oxygen to the cells and remove CO2
• Important facts to remember – gas always
takes the path of least resistance and flows
from a higher pressure to a lower pressure.
Introduction to the
Respiratory System
• Primary function is the absorption of O2 and excretion of
CO2 called “external respiration”
• “Internal respiration” gas exchange between tissue cells
and systemic capillary blood
• During a lifetime, about 250 million liters partake in
external respiration.
– Performed with minimal work
• Secondary function: filters both inhaled contaminants and
small clots or chemicals from blood
Development of the Respiratory
System
• Extends from almost conception into childhood.
• During Canalicular phase, life becomes possible.
1
8/15/2022
Embryonic Period
• 0-6weeks
• Lung Buds Appears followed by 2 branches
• Airway Branching begins
• Diaphragm begins to develop
Pseudo glandular Period
• 7-16 weeks
• Branching continues to terminal bronchi
• Mucus glands form
• Diaphragm develops
• Cilia cells appear
Canalicular Period
• 17-26 weeks
• Airways increase in length and diameter
• Formation of Alveolar ducts
• Appearance of Type I and Type II cells
(immature surfactant)
• Pulmonary capillaries proliferate
2
8/15/2022
Terminal sac and Alveolar Period
• 27 weeks to 8 years old
• Appearance of Alveoli
• Merger of alveolar epithelium and
pulmonary capillaries
• Appearance of mature surfactant
• Alveoli increase in size and number
Chest Wall Development,
Diaphragm and Lung Volume
• Infant thorax is more compliant than that of an adult.
• FRC is established by the equal and opposing forces of
chest wall to expand against the lungs tendency to
collapse.
. .
• The infant’s more compliant thorax results in lower FRC
and TLC.
– Predisposes infant to early airway closure, atelectasis, V/Q
mismatch, and hypoxemia
– Combated by ending expiration early, results in gas
trapping, narrowing the glottis, back pressure
• Patient will make a grunting sound
Fetal Lung Development
• At end of Canalicular phase, primitive acini form,
covered with type I and II pneumocytes.
– Life viable if airway, MV, surfactant provided
• During terminal saccular stage more acini form.
– There is thinning of the type I cells
– Type II cells mature and produce surfactant.
• Alveolar stage begins at about 32 weeks.
– Mature alveoli/capillary membranes appear.
• At birth, about 50 million alveoli are present.
– By age 8, there will be about 300 million.
3
8/15/2022
The Fetal Lung
• Lung maturation is determined by surfactant.
– Phosphatidylcholine levels predictive
• Lecithin/sphingomyelin ratio (L/S ratio)
• Phosphatidylglycerol (PG) concentration
• Fetal lung fluid is constantly produced
– Slight positive pressure keeps lungs inflated.
• Promotes normal lung development
• At birth, lungs hold about 40 ml of fluid.
• If deficient, can result in hypoplastic lung
Lymphatic and Nervous
Development
• Lymph nodes and vessels are located in connective tissues
beside pulmonary structures
– Provide fluid control and defense
• Absorbed fluid travels to hilar lymph nodes
• Nervous tissue development
– Brainstem centers for automatic control
– Phrenic and intercostal nerves form to carry motor signals to
diaphragm and intercostal muscles
– Autonomic fibers form for smooth muscle control
Vascular Development
• Basic structure is in place at birth.
• Subsequent vascular growth involves increased smooth
muscle growth and increased density of arterioles and
capillaries in distal regions.
• Lungs are unique as blood from RV and LV provide flow
to alveoli microcirculation.
– Pulmonary circulation from RV
– Bronchial circulation from LV
– Provides greater stability and resistance against the impact
of disease processes
4
8/15/2022
Postnatal Upper Airway
• Head flexion can cause airway obstruction.
• Factors contributing to airway obstruction
– Tongue is relatively larger compared with adults.
– Nasal passages are relatively smaller.
• Most infants nose breathe exclusively.
• At 4 to 5 months, most infants can breathe orally.
– Infections or Intubations can cause obstruction at the cricoid
cartilage (narrowest point) or the epiglottis, which is relatively
longer and less flexible than that of an adult.
Fetal Circulation (cont.)
• In utero fetal lungs have high PVR due to low PAO2.
– Ductus Arteriosus shunts blood from high-resistance
pulmonary artery to low-resistance aorta.
Fetal Circulation
• Placenta large volume, low resistance system, so fetal
SVR is low
• Umbilical vein returns oxygenated blood from the
placenta to fetus via the Ductus Venosis.
• Flows into the IVC and on to the RA
• Oxygenated blood is preferentially shunted through the
foramen ovale from the right to the left atrium.
– Provides oxygenated blood to systemic circulation
5
8/15/2022
Uterine Life
• In utero life depends on placental structure, which
provides, among many things:
– Gas exchange
– Nutrients and waste removal
– Defense against disease
• Fetal circulation incorporates the placenta by the
umbilicus and use of three special shunts:
– Ductus Venosis, Ductus Arteriosus, and foramen ovale
Uterine Life (cont.)
Placenta
• Source of gas exchange for fetus
• Gas exchange occurs at between chorionic
villi known as intervillous space
• Blood comes to the placenta via the 2
umbilical arteries
• Oxygenated blood leaves placenta via the
umbilical vein
6
8/15/2022
Umbilical Chord
• Contains 2 umbilical arteries and one
umbilical vein
• Wharton Jelly is between vessels to provide
support
Functions of Amniotic Fluid
• Protection from traumatic injury
• Thermoregulation
• Facilitation of fetal movement
• Normal Fluid level 500 to 1500 ml
Polydramnios
• Too much amniotic fluid > 2000ml
• Indicates a problem with swallowing
mechanism of fetus – CNS Malformation,
cleft palate, Downs syndrome, congenital
heart disease
7
8/15/2022
Oligohydramnious
• Too little amniotic fluid
• Due to defect in urinary system
Blood gas values in Utero
• Umbilical Artery • Umbilical Vein
• pH 7.33 • pH 7.35
• PCO2 46 • PCO2 42
• PO2 16 • PO2 29
Low Oxygenation
• Diffusion Limitation
• Shunts
• Oxygen consumption of Placenta
• Fetal HB high affinity for Oxygen results in
higher Sat with lower PaO2
8
8/15/2022
Cardiopulmonary Events at Birth
• Fetal lung fluid
– Prior to birth, production stops and absorption starts.
– One third of fluid is expelled by vaginal squeeze.
– Pulmonary lymphatics absorb remaining fluid.
• Tactile and thermal stimuli initiate first breath.
– Initial breath requires trans pulmonary pressures >40 cm
H2O.
– Subsequent breaths require progressively less pressure as
lung volume increases.
Cardiopulmonary Events at Birth
(cont.)
• Air in lung increases PO2 and pH, while PCO2 decreases,
which results in:
– Pulmonary vasodilation and decreased PVR
– Ductus arteriosus constriction/closure
– Increased pulmonary blood flow
• At the same time, placenta removal results in:
– Sudden increase in SVR
• Net results:
– LAP > RAP, so foramen ovale closes
– Transition to extra uterine circulation complete
