ANATOMICAL &

PHYSIOLOGICAL DIFFERENCE
IN ADULT & PAEDIATRIC LUNG

Dr. Amber Jamaal PT

ANATOMICAL DIFFERENCES
RIB CAGE & CHEST SHAPE
CHEST SHAPEThe cross-sectional shape of the infant thorax is cylindrical & not
elliptical ass in adolescents or adults.
RIBSThe ribs of the newborn infant are relatively soft & cartilaginous compared with
the more rigid chest wall of older children & adults.They’re placed horizontally to the
sternum & vertebral column, when compared to oblique rib angle in adults. Therefore
no bucket handle rib movement in newborns.
INTERCOSTAL MUSCLESPoorly developed in infancy & its contraction is
inefficient.
DIAPHRAGM
The angle of insertion of the infant diaphragm is horizontal compared with older
children or adults, placing it at a mechanical disadvantage.
The infant diaphragm has a lower relative muscle mass and a lower content of high-
endurance muscle fibres, and thus is much more rulnerable to fatigue.
PREFERENTIAL NASAL BREATHING

The shape and orientation of head and neck in babies mean that the airway is prone to
obstruction in young infants.
Young infants up to about 6 months of age are preferential nasal breathers and studies
suggest that up to half of all neonates are unable to breathe through their mouths,
except when crying, for the first few weeks of life.
Therefore, even a small amount of swelling or obstruction of the nasal passages of
infants compromises breathing considerably and causes a disproportionate and
detrimental effect on the work of breathing. Some young infants with upper
respiratory tract infections and partial obstruction their nasal passages can develop
respiratory distress.
POSITION OF THE LARYNX
In the newborn infant, the larynx and hyoid cartilage are higher in the neck and closer
to the base of the epiglottis, being at the level of C3 in a premature infant and C4 in a
child compared with C5-6 in the adult.
The larynx descends with age, but its high position enables the infant to feed and
breathe simultaneously for approximately the first 4 months of age.
High position of larynx- protection of the airway in infants younger than 4-6months
because it acts as a valve, which helps keep food in the mouth until the pharyngeal
swallow is initiated.
The airway has less anatomical protection as the larynx assumes its lower position in
the neck and is not as directly protected by the epiglottis. Then, poor closure of the
airway or partial paralysis of the vocal folds may become more evident and coughing,
choking or aspiration may occur.
AIRWAY DIAMETER
The neonatal trachea is short (4-9 cm) and directed downward and posteriorly. The
diameter of the trachea in the newborn is 4-5 mm and the diameter of an infant trachea
is only about one-third that of an adult.
This makes respiratory resistance higher and the work of breathing greater
At birth there is no further increase in the number of airways formed but there is
growth and development in their size. In the first few years of life there is a significant
increase in the diameter of the larger, more proximal airways (Hislop & Reid 1974).
The smaller, more distal airways do not increase in diameter until nearer 5 years of
age.
BRONCHIAL WALLS

The bronchial walls contain proportionally more cartilage, connective tissue and
mucous glands than do those of adults, but less smooth muscle; this makes the lung
tissue less compliant.
The lack of bronchial smooth muscle, particularly in the smaller bronchioles, may be
one reason for the lack of response to bronchodilators under the age of 12 months.
The B-receptors in infants are also immature, which further reduces any response to
B-adrenergis bronchodilator therapy (Reid 1984).
The high proportion of mucous glands in the major bronchi of infants makes the
airways more susceptible to mucus obstruction.
CILIA

At birth, the cilia are poorly developed - increases risk of secretion retention,
especially in premature infant.
Airway obstruction caused in a neonate is much greater than in adults - who have
relatively larger airways.
ALVEOLI & SURFUCTANT
ALVEOLI : True alveoli develop only after about 36 weeks' gestation.A term newborn
has an average of 150 million alveoli.Both the number and size of alveoli continue to
increase postnatally until the chest wall stops growing. By 4 vears of age, the adult
number of 300 million may exist, although growth can continue until 7 years of age.
The smaller alveolar size of an infant - more susceptible to alveolar collapse, and the
smaller number of alveoli reduces the area available for gaseous exchange.
SURFACTANT : Pulmonary surfactant acts to reduce surface tension at the air-liquid
interface in the alveolus. Preterm newborns- development of Neonatal Respiratory
Distress Syndrome, due to surfactant deficiency. Male gender at more risk.
COLLATERAL VENTILATION
Collateral Ventilation is the means by which a distal lung unit can be ventilated,
despite blockage of its main airway.
The collateral ventilatory channels between alveoli, respiratory bronchioles &
terminal bronchioles is poorly developed until 2-3 years of age, thereby predisposing
towards alveolar collapse.
INTERNAL ORGANS & LYMPHATIC TISSUE

The lymphatic tissue - enlarged in the infant & tongue is also relatively large , both
leading to upper airway obstruction.
The heart & other organs are relatively large in infants, leaving less space for lung
expansion.
HEIGHT & EXPOSURE TO AIR POLLUTION

Because children breathe more rapidly compared with adults and because they spend
more time outdoors being physically active, they tend to be more exposed to outdoor
air pollution and allergens than do adults.
Their reduced height means they are also more exposed to vehicle exhausts and
heavier pollutants that concentrate at lower levels in the air. There is substantial
evidence linking air pollution with respiratory health problems and children are more
vulnerable
PHYSIOLOGICAL
DIFFERENCES
RESPIRATORY COMPLIANCE

The Respiratory compliance is a measure of the pressure required to increase the

volume of air in the lungs and reflects a combination of lung and chest wall compliance.
The lung compliance of a child is comparable to that of an adult, being directly
proportional to the child's size.
Compliance is reduced in the infant because of the high proportion of cartilage in the
airways. The premature infant, who lacks surfactant, demonstrates a further significant
decrease in compliance. The chest wall of an infant is cartilaginous and therefore very
soft and compliant in comparison with the more calcified and rigid adult structure.
Neonates therefore have an imbalance between a relatively low outward recoil of their
chest wall and normal inward elastic recoil, which means that they are prone to airway
collapse.
CLOSING VOLUME
The closing volume is the lung volume at which closure of the small airways occurs.
Closing volume + residual volume = Closing capacity (CC)
In adults, CC>FRC
The higher closing volumes in infants - due to greater chest wall compliance &
reduced elastic recoil of the lungs than in adults
VENTILATION & PERFUSION

In the adults, both ventilation & perfusion are preferentially distributed to the
dependant lung. The best gas exchange & ventilation/perfusion ratio will therefore be
in the dependant region of the lung.
In the infants, ventilation is preferentially distributed to the uppermost lung, whereas
the perfusion remains best in the dependant regions. This leads to greater gas
exchange in the uppermost lung , but an imbalance between perfusion & ventilation.
The difference in ventilation distribution between infants & adults is due to more
compliant ribcage of the infant, which compresses the dependant area of the lung
OXYGEN CONSUMPTION, CARDIAC OUTPUT & RESPONSE
TO HYPOXIA
Infants have a higher resting metabolic rate than adults and consequently have a
higher oxygen requirement.
Children have a higher cardiac output and oxygen consumption per kilogram than
adults; in infants this may exceed 6 ml/kg/min, twice that of adults. They support this
higher output with a higher baseline heart rate but lower blood pressure than adults.
An infant responds to hypoxia with bradycardia and pulmonary vasoconstriction,
whereas the adult becomes tachycardic with systemic vasodilation. The bradycardic
response in infants is probably due to myocardial hypoxia and acidosis, but leads to an
immediate reduction in cardiac output and the development of further hypoxia.
MUSCLE FATIGUE
The respiratory muscles of infants tire more quickly than those of adults due to a
much smaller proportion of fatigue-resistant muscle fibre (Keens & lanuzzo 1979).
There are two main muscle fire types, type I and type II.
Type I muscle fibres are slow twitch, high oxidative and slow to fatigue.
Type II fibres are fast twitch, slow oxidative and tire quickly.
Of the muscle fibres in the adult diaphragm, 55% are type I compared with only 30%
in the infant. Premature infants tire even more easily as, at 24 weeks' gestation, only
10% of their muscle fibres are fatigue resistant (Muller & Bryan 1979).
Excesssive muscle fatigue results in apnoea. By 12 months of age the number of type
I fibres equals that of an adult.
BREATHING PATTERN & REM SLEEP
Irregular breathing patterns and episodes of apnea are relatively common in neonates,
especially if premature and are related to immature cardiorespiratory control.
Short spells of apnoea can be considered normal in the circumstances, but need
careful monitoring as they me reflect hypoxic conditions.
During rapid eye movement (REM) sleep there is reduction in postural tone and tonic
inhibition of the infant's intercostal muscles such that the rib cage is even less well
equipped to counteract the contraction of de diaphragm during inspiration
This reduces the efficiency of respiration, causes a drop in functional residual capacity
and increases the work of breathing, predisposing the infant to apnoetic episodes
(Muller & Bryan 1979). The premature infant is most at risk, spending up to 20 hours
a day aslep of which may be in active REM sleep compared with 20% in adult sleep.
RESPONSE TO COLD

Pediatric patients have an increased surface area per kilogram and lose heat to the
environment more readily than adults. This is compounded by cold intravenous fluids,
dry anaesthetic gases and exposure.
Non-shivering thermogenesis in brown adipose tissue is the major mechanism of heat
production during the first few months of life. Brown fat is specialized tissue located
in the posterior of the neck, along the interscapular and vertebral areas, and
surrounding the kidneys and adrenal glands.
Metabolic heat production can increase up to two and a half times during cold stress.
Shivering is a less economical form of heat production but does occur in severely
hypothermic neonates. Hypothermia is a serious problem that can result in increased
oxygen consumption, cardiac irritability and respiratory depression (King & Booker
2004).
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