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1 INTRODUCTION 1

Introduction 2

What is respiration? 2

The need for respiration 2

Diffusion in respiration and the circulation 3

Timing in the circulation and respiration 3

Basic science of respiration 3

Drugs 9

2 STRUCTURE OF THE RESPIRATORY SYSTEM,RELATED TO FUNCTION 11

Introduction 12

The upper airways 12

The intrathoracic airways 15

Blood vessels 18

Pulmonary hypertension 18

The lymphatics 19

The nerves 19

Gross structure of the respiratory system 19

Pleurisy 20

The diaphragm and chest wall 20

How breathing is brought about 22

Embryology 23

Air-conditio ning 24

Metabolic activity 26

Metabolism of circulating biologically active substances 27

Non-respiratory functions 27

3 ELASTIC PROPERTIES 0F THE RESPIRATORY SYSTEM 29

Introduction 30

Intrapleural pressure(Ppl) 30

Static lung compliance(CL) 31

The effect of disease 32

The physical basis of lung compliance 32

4 AIRFLOW IN THE RESPIRATORY SYSTEM 41

Introduction 42

How airflow is brought about 42

The nature of airflow 43

The major determinant of flow-radius 43

Airways resistance and obstructive pulmonary disease 43

The clinical situation 45

Sites of airways resistance 46

Asthma and airways smooth muscle 48

Bronchomotor tone 49

Pharmacological treatment of asthma 50

Clinical definitions 50

Bronchitis and mucus 52

Emphysema and radial traction 53

Intrapleural pressure and cough 54

Clinical tests for changes in resistance 57

Work of breathing 57

5 VENTILATION OF THE RESPIRATORY SYSTEM:THE IMPORTANCE OF ITS LACK OF UNIFORMITY IN DISEASE 61

Introduction 62

Spirometric abnormalities in disease 63

Uneven distribution 64

Dead space 64

Alveolar dead space in disease 65

The Bohr equation 66

Factors affecting physiological dead space 68

Alveolar ventilation and respiratory exchange 68

The alveolar gas equation 69

Distribution of inspired gas 69

Other factors influencing distribution 72

6 GAS EXCHANGE BETWEEN AIR AND BLOOD:DIFFUSION 77

The path from air to tissue 78

Lung disease and diffusion 79

Fick's Law of Diffusion 79

Measuring transfer factor 82

Treating diffusion difficulties 83

Carbon dioxide and other gases 83

7 THE PULMONARY CIRCULATION:BRINGING BLOOD AND GAS TOGETHER 85

The functions of the pulmonary circulation 86

The anatomy of the pulmonary circulation 86

Matching ventilation and perfusion 89

Distribution of blood flow through the lungs 89

Regional differences in ventilation in the lungs 94

Ventilation/perfusion matching and its effect on blood O2 and CO2 content 95

Shunt 97

8 CARRIAGE OF GASES BY THE BLOOD AND ACID/BASE BALANCE 99

Introduction 100

Oxygen transport 100

Dissolved oxygen:do we really need Hb and why keep it in red cells? 108

Carbon dioxide transport 109

Acid-base balance 113

9 CHEMICAL CONTROL OF BREATHING 119

Introduction 120

Oxygen lack 120

Carbon dioxide excess 125

10 NERVOUS CONTROL OF BREATHING 129

Introduction 130

The rhythm generator 131

Pattern of breathing in COPD 132

The respiratory ' centres' 133

The medullary groups 133

Conscious control of breathing 134

Respiratory muscle innervation 135

Neuromuscular disorders 137

Vagal reflexes 137

Dyspnoea 140

Other reflexes 140

11 LUNG FUNCTION TESTS:MEASURING DISABILITY 143

Introduction 144

Spirometry 144

Flow measurements 145

Plethysmography 145

Lung mechanics 146

Transfer factor(diffusing capacity) 147

Blood gases 148

Gas washouts 148

Exercise testing 150

Challenge tests 151

Appendix:some basic science 153

Glossary 159

Index 165