2/13/2017 Anatomyandphysiologyofrespiratorysystemrelevanttoanaesthesia

IndianJAnaesth.2015Sep59(9):533541. PMCID:PMC4613399
doi:10.4103/00195049.165849

Anatomyandphysiologyofrespiratorysystemrelevanttoanaesthesia
ApekshPatwa1,2andAmitShah1,2
1
KailashCancerHospitalandResearchCentre,MuniSevaAshram,Goraj,Vadodara,Gujarat,India
2
DepartmentofAnaesthesia,VadodaraInstituteofNeurologicalSciences,Vadodara,Gujarat,India
Addressforcorrespondence:Dr.ApekshPatwa,B31/32,KailashParkDuplex,AimsOxygenLane,AksharChowk,OldPadraRoad,Vadodara390
020,Gujarat,India.Email:apekshpatwa@gmail.com

Copyright:IndianJournalofAnaesthesia

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNonCommercialShareAlike3.0License,whichallows
otherstoremix,tweak,andbuildupontheworknoncommercially,aslongastheauthoriscreditedandthenewcreationsarelicensedundertheidentical
terms.

Abstract Goto:

Clinicalapplicationofanatomicalandphysiologicalknowledgeofrespiratorysystemimprovespatient'ssafety
duringanaesthesia.Italsooptimisespatient'sventilatoryconditionandairwaypatency.Suchknowledgehas
influenceonairwaymanagement,lungisolationduringanaesthesia,managementofcaseswithrespiratory
disorders,respiratoryendoluminalproceduresandoptimisingventilatorstrategiesintheperioperativeperiod.
Understandingofventilation,perfusionandtheirrelationwitheachotherisimportantforunderstandingrespiratory
physiology.Ventilationtoperfusionratioalterswithanaesthesia,bodypositionandwithonelunganaesthesia.
Hypoxicpulmonaryvasoconstriction,animportantsafetymechanism,isinhibitedbymajorityoftheanaesthetic
drugs.Ventilationperfusionmismatchleadstoreducedarterialoxygenconcentrationmainlybecauseofearly
closureofairway,thusleadingtodecreasedventilationandatelectasisduringanaesthesia.Variousanaestheticdrugs
alterneuronalcontrolofthebreathingandbronchomotortone.

Keywords:Anatomy,bronchomotortone,functionalresidualcapacity,physiology,respiratorysystem,
tracheobronchialtree,ventilationperfusion

INTRODUCTION Goto:

Accurateknowledgeofanatomyandphysiologyoftherespiratorytractisimportantnotonlyinthefieldof
pulmonologybutalsoinanaesthesiologyandcriticalcare.About7080%ofthemorbidityandmortalityoccurring
intheperioperativeperiodisassociatedwithsomeformofrespiratorydysfunction.[1]Generalanaesthesiaand
paralysisareassociatedwithalterationsintherespiratoryfunction.[2,3]Dynamicanatomicalchangesand
physiologicalalterationhappeningduringanaesthesiamakeitimperativeforananaesthesiologisttohavesound
knowledgeoftherespiratorysystemandapplyitforsafeandsmoothconductofanaesthesia.Suchknowledgehas
influenceonclinicalpracticeofairwaymanagement,lungisolationduringanaesthesia,managementofcaseswith
respiratorydisorders,respiratoryendoluminalproceduresandsurgeries,optimisingventilatorstrategiesin
perioperativeperiodanddesigningairwaydevices.

ANATOMYOFRESPIRATORYSYSTEM Goto:

Therespiratorysystem,functionally,canbeseparatedintwozonesconductingzones(nosetobronchioles)forma
pathforconductionoftheinhaledgasesandrespiratoryzone(alveolarducttoalveoli)wherethegasexchange
takesplace.Anatomically,respiratorytractisdividedintoupper(organoutsidethoraxnose,pharynxandlarynx)
andlowerrespiratorytract(organwithinthoraxtrachea,bronchi,bronchioles,alveolarductandalveoli).

Thediscussionismainlyconcentratedonthelowerrespiratorytractandtherelatedphysiology.

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Noseandnasalcavityaredividedintotwohalvesbythenasalseptum.Thelateralwallofthenoseconsistsofthree
turbinatesorconchae(superior,middleandinferior).Thepassageinferiortoinferiorturbinateispreferredpassage
fornasotrachealintubation.[4]Thepharynxisatubelikepassagethatconnectstheposteriornasalandoralcavities
tothelarynxandoesophagus.Itisdividedintonasopharynx,oropharynxandlaryngopharynx.Increaseinsoft
tissuewithinbonyenclosureofpharynxordecreaseinbonyenclosuresizewouldresultinanatomicalimbalance
andcauselimitationofspaceavailableforairway[Figure1].[5]

Figure1
Excessivesofttissue(obesity)infixbonyenclosureleadstocompromised
pharyngealpassage

Therearethreenarrowestportionsofpharynxpassageposteriortothesoftpalate(retropalatalspace),passage
posteriortothetongue(retroglossalspace)andpassageposteriortoepiglottis(retroepigloticspace).Thereis
significantreductionofthesespaceswithsedationandanaesthesia[6]whichwouldleadtoupperairway
obstruction.

ANATOMICALFACTORSWHICHCOMPROMISESPHARYNGEALPATENCY Goto:

Inefficientcontractionofpharyngealdilatormuscles[Figure2]

Figure2
Upperairwayshowingpharyngealdilatormusclesandpharyngealairway
space

(1)Thetensorpalatineretractsthesoftpalateawayfromtheposteriorpharyngealwall,therebymaintainingretro
palatalpatency.(2)Thegenioglossusmovesthetongueanteriorlytoopentheretroglossalspace.(3)Hyoidmuscles
(geniohyoid,sternohyoidandthyrohyoid)makethehyoidmoveanteriorlyandstabilisetheretroepiglotic
laryngopharynx.Excessivefatdepositionaroundthesemuscleswouldresultininefficientcontractionofpharyngeal
dilatormuscles.Thiswouldleadtopharyngealairwayobstructionduringsedationandanaesthesia.[7]

Anatomicalimbalanceoforopharyngealsofttissue
Enlargedtongue(inthecaseofacromegalyorobesity)innormalbonyenclosureoforopharynxorasmallerbony
enclosure(recedingmandible)oforopharynxwouldbeunabletoaccommodatethetongueintooropharynxand
thusshiftthetongueintohypopharynx(laryngopharynx).Hypopharyngealtonguedecreaseslaryngopharyngeal
airwaypatency.Thisisonereasonforobstructivesleepapnoeaanddifficultmaskventilationduringanaesthesia.[8]

Trachealtug
Thereisconstanttractionontrachea,pharynxandlarynxduringinspirationbecauseofnegativeintrathoracic
pressurewhichelongatespharyngealairwayduringinspirationthatwouldresultindecreasedpharyngealluminal
spaceinobesepatients.Thisisalsooneofthereasonsfordifficultmaskventilationandobstructivesleepapnoea.
[9]

Larynx
Itservesasasphincter,transmittingairfromoropharynxandnasopharynxtotrachea.

TRACHEOBRONCHIALTREE Goto:

Itisacomplexsystemthattransportsgasesfromthetracheadowntotheacini,thegasexchangeunitsofthelung.It
ispartitionedinto23generationsofdichotomousbranching,extendingfromtrachea(generation0)tothelastorder
ofterminalbronchioles(generation23).Ateachgeneration,eachairwayisbeingdividedintotwosmallerdaughter
airways[10][Figure3].

Figure3
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Tracheobronchialtreeshowing23generations

Fromthetracheatotheterminalbronchioles(generation1516),theairwaysarepurelyconductingpipes.Sinceno
gasexchangestakeplaceinthisregion,thevolumeinthesepipesiscalledasthedeadspacevolume(average150
ml).Theterminalbronchioles(generation16)divideintorespiratorybronchiolesortransitionalbronchioles
(generations1719)astheyhaveoccasionalalveoliatthewalls.Theserespiratorybronchiolesfurtherdivideinto
alveolarducts(generations2022)whicharecompletelylinedwithalveoli.Thisregionisknownasacinus
(generations1623).Theacinusiscomprisedofrespiratoryairwaysandformsfunctionaltissues(gasexchange
units)oflung.Thealveolarductsaresmalltubessupportedbyarichmatrixofelasticandcollagenfibres.Thedistal
endsofalveolarductsopenintothealveolarsacwhichismadeupbyalveoli.

TRACHEAANDRIGHT/LEFTMAINBRONCHUS Goto:

Thetracheaisahollowconduitforgasesandbronchialsecretions.ItextendsfromthelevelofC6(cricoid
cartilage)tothecarina,approximatelylocatedatthelevelofT4T5.[11]Inadults,itslengthisapproximately1113
cm,with24cmbeingextrathoracic.[12]Thetracheahas16to22horseshoebands(cshaped)ofcartilages.The
posteriortrachealwalllackscartilageandissupportedbythetrachealismuscle.Dependingonthelevelof
inspiration,theposteriorwallofthetracheabecomesflat,convexorslightlyconcave.[13,14]Theposteriorwallof
thetracheaeitherflattensorbowsslightlyforwardduringexpiration.Innormalsubjects,thereisupto35%
reductioninanteroposteiortracheallumeninforcedexpiration,whereasthetransversediameterdecreasesonlyby
13%.[15]Thetracheaisgenerallymidlineinposition,oftendisplacedslightlytotherightandposteriorlyasit
approachescarina.Theangleofthetrachealbifurcationiscalledasthecarinal/subcarinalangle,whichismeasured
commonlyas73(3590).[16,17,18]Thecarinalangleiswiderinindividualswithanenlargedleftatrium,in
femalesandobesepatients.

Thetracheadividesatcarinaintotherightandleftmainbronchus.Thedistanceofthecarinafromtheteethvaries
markedlywithchangeinneckpositionfromflexiontoextension(tracheallengthvariationis2cm),bodyposition
andpositionofdiaphragm.[19]Thisexplainsthechangeinpositionofendotrachealtubeduringchangeinposition
ofpatientorflexionextensionofneck.Therightmainstembronchushasamoredirectdownwardcourse,is
shorterthantheleftandbeginstoramifyearlierthantheleftmainbronchus.[11]Thisleadstohigherchancesof
rightendobronchialintubation.Therightmainstembronchusdividesinto(secondarybronchi)rightupperlobe
bronchusandbronchusintermediuswhichfurtherdividesintorightmiddleandlowerlobebronchus.Theleft
bronchuspassesinferolaterallyatagreateranglefromtheverticalaxisthantherightbronchus.Theleftmainstem
bronchusdividesinto(secondarybronchi)theleftupperandlowerlobebronchi.

BRONCHOPULMONARYSEGMENT Goto:

Bronchopulmonarysegmentmaybedefinedasanareaofdistributionofanybronchus[Figure4].Eachlobar
bronchidividesintosegmentalbronchi(tertiarybronchi),whichsupplythebronchopulmonarysegmentofeach
lobe.Technically,therearetenbronchopulmonarysegmentsineachlung,butinleftlung,someofthesesegments
fuseandthereareasfewaseightbronchopulmonarysegments.Thebronchicontinuetodivideintosmallerand
smallerbronchiupto23generationsofdivisionsfrommainbronchus.Asbronchibecomesmaller,theirstructure
changes:

Figure4
Tracheobronchialtreewithbronchopulmonarysegments

Cartilaginousringbecomesirregularandthendisappear.Whenbronchiloseallcartilaginoussupport,the
airwayisthenreferredasbronchioles
Theepitheliumchangesfrompseudostratifiedcolumnartocolumnartocuboidalintheterminalbronchioles
Therearenociliaandmucousproducingcellsinbronchioles
Theamountofsmoothmuscleinthetubewallincreasesastheairwaybecomessmaller.

DIMENSIONSOFTRACHEOBRONCHIALTREE[TABLE1]
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DIMENSIONSOFTRACHEOBRONCHIALTREE[TABLE1] Goto:

Table1
Dimensionsandfeaturesoftracheobronchialtree

Ascertainingtheparametersoftracheobronchialtreesuchaslength,diametersandangulationshelpsoptimizing
proceduressuchasintubation,lungisolationtechniquesandjetventilationduringinterventionalendoscopic
surgeriesoftracheaorbronchi.[20]

Tracheobronchialanatomicalvariations
Tracheobronchialtreeexhibitsawiderangeofvariationsanditsprevalenceis4%.[28]Themostcommonmain
bronchusanomaliesarethetrachealbronchusandtheaccessorycardiacbronchus.Knowledgeoftracheobronchial
variantsisimportantforclinicalaspectinpreoperativeevaluationinviewofintubation,lungisolationtechniques
andotherendobronchialprocedures.

Trachealbronchus Thisisabronchususuallyoriginatingfromtherightsideofthetracheaabovethecarinaand
within26cmfromit.[29]Righttrachealbronchushasaprevalenceof0.12%andleftbronchushasaprevalence
of0.31%.[30,31,32,33,34]Thetrachealbronchusmaycausecomplicationssuchasatelectasisorpneumothoraxin
thecasesofobstructiontoitsentranceortubeenteringintoitduringintubation.[35,36,37]

Accessorycardiacbronchus Itisacongenital,shortandthinbronchustowardspericardiumoriginatingeither
fromrightbronchusorintermediatebronchus.Itsprevalenceis0.08%.[31]Itisassociatedwithrecurrentinfections
infewcases.[38]

PHYSIOLOGYOFRESPIRATORYSYSTEM Goto:

Movementofinspiredgasintoandexhaledgasoutoflungiscalledasventilation.Understandingoflungvolumes,
lungcompliance,ventilationperfusionandbronchomotortoneareessentialforclinicalapplicationofrespiratory
physiologyinanaesthesiaandcriticalcare.

Lungvolumes[Figure5]

Figure5
Lungvolumes

Normalrequirementsofthebodycanbeeasilymetbynormaltidalventilationwhichisapproximately48ml/kg.
Bodyhaskeptmechanismtoprovideextraventilationintheformofinspiratoryreservevolumeandexpiratory
reservevolumewheneverrequired(e.g.,exercise).Whenanindividual,aftertidalexpiration,takesfullinspiratory
breathfollowedbyexpirationtoreservevolume,itiscalledasvitalcapacitybreathandis45Linanaverage70
kgindividual.Thereisalwayssomeamountofairremaininginthealveoliwhichpreventsitfromcollapsing.The
volumeremaininginthelungsaftervitalcapacitybreathiscalledasresidualvolume.

Residualvolumewithexpiratoryreservevolumeiscalledasfunctionalresidualcapacity(FRC).FRCisbasically
theamountofairinthelungsafteranormalexpiration.Gasesremaininginthelungsattheendofexpirationnot
onlypreventalveolarcollapsebutalsoitcontinuestooxygenatethepulmonarybloodflowingthoughthe
capillariesduringthistimeperiod.[39]ReportedFRCvaluesvarywithvariousreportsbutonaverageitisbetween
2.8and3.1L[40]instandingposition.FRCvarieswithchangeofposition,anaesthesiaandbodyweight.FRCis
thereservewhichprolongsnonhypoxicapnoeatime.

Theportionoftheminuteventilationwhichreachesalveoliandtakespartinthegasexchangeiscalledasalveolar
ventilation.Normalvalueofalveolarventilationisapproximately5L/minwhichissimilartothevolumeofblood
flowingthroughthelung(cardiacoutput5L/min).Thismakesalveolarventilationtoperfusionratioapproximately
one.[39]

RESPIRATORYMECHANICS Goto:

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Lungsarelikeinflatableballoonwhichdistendactivelybypositivepressureinsideand/ornegativepressurecreated
inpleuralspace.Innormalrespiration,negativepleuralpressure(Ppl)issufficienttodistendthelungsduring
inspiratoryphase.Understandingofdistendingpressureisveryimportanttounderstandtherespiratorymechanics.
Distendingpressurecanbeknownastranspulmonarypressure(Ptp),whichisexpressedbythefollowingequation:

Ptp=PawPpl,(Ptp=transpulmonarypressure,Paw=alveolarpressure,Ppl=Pleuralpressure).

Complianceandventilationoflung
ComplianceisexpressedasthedistensionoflungforagivenlevelofPtp.Itisusually0.20.3L/cmH2O.[41]
Compliance(abilityoflungtodistend)dependsuponthevolumeofthelung.Complianceislowestatextremesof
FRC.Itimpliesthatexpandedlungandcompletelydeflatedlunghaslowercapacitytodistendtoagivenpressure[
Figure6].Intheuprightlung,intraPplvariesfromthetoptothebaseofthelungs.IntraPplbecomes0.2cmH2O
positiveforeverycentimetredistancefromapextobaseoflung.Averageheightoflungisabout35cm.Inquite
breathing,theintraPplatapexisabout8cmofH2Owhileatbaseitis1.5cmofH2O.Thismeansthatthe
alveoliattheapexareexposedtoagreaterdistendingpressure(PAPpl=0(8)=8cmH2O)comparedtothose
atthebase(PAPpl=0(1.5)=1.5cmH2O).Asalreadydistended,apicalregionbecomeslesscompliantthan
otherareaoflung.Thisexplainsthepreferentialdistributionofventilationtothealveoliatthebaseofthelungsin
uprightposture.DistributionofventilationchangeswiththepositionofindividualbecauseofthechangeofPpl
withthegravity.

Figure6
Transpulmonarypressure

Airwayclosureduringexpirationisnormalphenomenon,withreopeningofairwaysduringthesucceeding
inspiration.[42]ThevolumeremainingabovetheresidualvolumewhereexpirationbelowFRCclosessome
airwaysistermedasclosingvolumeandthisvolumeaddedtotheresidualvolumeistermedastheclosingcapacity.
Inuprightposition,closingcapacityapproachesnearFRCinolderindividual(6570years)whichwouldresultin
airwayclosureevenatnormaltidalexpiration.Changeinbodypositionfromuprighttosupine,lateralorprone
reducesFRC.ReductioninFRCpromotesairwayclosureindependentlungregions.Earlyairwayclosurethus
decreasesventilationinthedependentregions.Sincelungbloodflowpassespreferentiallytodependentregions,
matchingbetweenventilationandperfusionisimpeded.[43]

Perfusionoflung
Pulmonarycirculationdiffersfromsystemiccirculation.Thepulmonaryvesselsarethinwalledandhaveless
musculaturetoassistfastdiffusionofgases.Theyaresubjectedtolesspressurecomparedtosystemiccirculation.
Becauseoflesspressureandstructuraldifferencesofpulmonaryvasculaturetoassistdiffusion,theyaresubjected
toPawinsidethethoraxandgravity.[44]

Onthebasisoftheinfluenceofgravity,perfusionoflungisdividedintothreezones.[45]Thedistributionofblood
flowinthesezonesdependsuponthreefactors:Alveolarpressure(PA),pulmonaryarterialpressure(Pa)and
pulmonaryvenouspressure(Pv).

ApicalregionwherePAcanbehigherthanPaandPvisconsideredaszoneI.SincePA>Pa>PvinzoneI,no
arterialbloodflowoccursandthiszoneisconsideredasphysiologicaldeadspace.ThoughsuchzoneIdonotexist
inhealthysubjectundernormalperfusionpressure,inconditionofhaemorrhageorpositivepressure,ventilation
zoneImaybecomerealityandaddstodeadspaceventilation.

InmiddlezoneorzoneII,differenceofPatoPAdecidestheperfusion(Pa>PA>Pv)whileinlowerzoneorzone
III,differenceofPatoPv(Pa>Pv>PA)decidestheperfusion.Fewstudiesalsoinclude4thzoneoflessblood
supplybecauseofthecompressionofvesselsduetotheweightoflungs.[46]

Thezonesdescribedearlierarepurelyphysiologicalandnotanatomical.Thebordersbetweenzoneschangeswith
manyphysiologicalandpathophysiologicalalterationsorconditions.Pawchangesareminimalduringthecourseof
aquietbreathbuttheyaremuchgreaterduringspeech,exerciseandotherconditions.Thepatientsonpositive
pressureventilationwithpositiveendexpiratorypressure(PEEP)mayhavesubstantialzoneIduetohighPAs.Pa
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alterswithseverehaemorrhageorduringgeneralanaesthesiaresultinginzoneIconditions.Pulmonaryartery
pressureishighduringexercise,eliminatinganyexistingzoneIintozoneIIandmovingtheboundarybetween
zonesIIIandIIupward

Ventilationtoperfusionmatching
Thealveolarpartialpressureofoxygenandcarbondioxidearedeterminedbytheratioofventilation(V)to
perfusion(Q).Asdiscussedearlier,ventilationandperfusionbothincreasefromtoptobottominlungs,but
perfusionincreasesmoreincomparisontoventilation.

Proportionately,ratioofventilationtoperfusionismoreinupperlungandlesstowardsthebaseoflungs[Figure7].
Thisgradientoccursinverticalaxisofthelungfieldsirrespectiveofbodypositions.(i.e.,ifpatientisinupright
posture,apexhasmoreventilationwhilebasehasmoreperfusion.Ifpatientisinlateralposture,nondependentlung
getsmoreventilationwhiledependentlunggetsmoreperfusion).

Figure7
Ventilationperfusionratiofromapextothebaseoflung

HYPOXICPULMONARYVASOCONSTRICTION Goto:

Hypoxicpulmonaryvasoconstriction(HPV)iscompensatorybloodflowawayfromhypoxiclungregionstobetter
oxygenatedregions.HPVoccursinresponsetolowalveolaroxygentension.ThismechanismimprovestheV/Q
mismatch.Allinhalationagentsexceptneweragents,sevofluraneanddesflurane,inhibittheHPV.[39]

PHYSIOLOGICALVARIATIONWITHPOSITIONANDANAESTHESIA Goto:

Supineposition
Generalanaesthesiapromotesbasalatelectasisirrespectiveofthemodesofventilation(spontaneousorcontrolled)
ordrugs(intravenousorinhalation)used.Nearly,1520%ofthelungisatelectaticduringgeneralanaesthesia.
Atelectasisdecreasestowardstheapex,whichusuallyremainsaerated.[42]Theareaofatelectasisbecomesthearea
ofshuntwherenogasexchangeoccursinspiteofperfusion.Earlyairwayclosureintidalbreathingwithsupine
position,promotesventilationperfusionmismatch(V/Q<1)andimpairmentofgasexchange.Thecombinationof
atelectasisandairwayclosureexplainsabout75%oftheoverallimpairmentinoxygenationinanaesthetised
subject.[47]

Lateralpositionandonelungventilation

Anaesthesiainlateralpositioncausesventilationperfusionmismatchwhereupperornondependentlungreceives
moreventilationandlowerordependentlungreceiveshigher(6065%)perfusion.Dependentlungalsoexhibits
signsofearlyairwayclosureandformationofatelectasis.WithadditionofPEEP,almost80%ofbloodflowis
directedtolowerdependentlung.[47]Duringonelungventilation,HPVcandivertbloodflowawayfromthenon
ventilatedlung.OneshouldavoiddrugscausinginhibitionofHPV.

Proneposition
Pronepositiondecreasesventilationperfusionmismatchandimprovestheoxygenation.Variousreasons(e.g.,
uniformverticaldistributionofperfusion,betterventilationdistributionbecauseofsmallerverticalpleuralgradient,
increasedFRC,moreuniformgasdistributionandlesslungcompressionbyheart)havebeenproposedbydifferent
authorsforimprovementinventilationwithproneposition.Therearenoreportsofatelectasisinproneposition,
probablybecauseweightofhearttransferredonthesternuminsteadoflungsasopposedtosupineposition.[42]

NEUROLOGICALCONTROLOFBREATHING Goto:

Therespiratorycentresarelocatedinponsandmedulla.Theycontaindifferenttypesofinspiratoryandexpiratory
neuronsthatfireduringthethreephasesoftherespiratorycycle,namelyinspiratoryphaseofsuddendischargeof
signalstoinspiratorymusclesandthedilatormusclesofthepharynx,followedbygradualdeclineofsignalsinpost

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inspiratoryphase.Inspirationisfollowedbynosignalsinexpiratoryphaseexceptinforcedexpirationorhigh
minuteventilation.[48]Inhalationalagentsinfluencerate,rhythmandintensityofdischargefromtherespiratory
centreswhichreceiveinputsfromthechemoreceptors,cortex,hypothalamus,pharyngealmechanoreceptors,vagus
nerveandotherafferents.Peripheralchemoreceptorsrespondquicklytohypoxia,hypercapniaandhydrogenion
concentration.Thecentralchemoreceptorsareslowrespondersrelativetoperipheralchemoreceptors.

BRONCHOMOTORTONE Goto:

Bronchomotortoneisthestateofcontractionorrelaxationofthesmoothmuscleinthebronchialwallsthat
regulatesthecalibreoftheairways.Numberoffactorsinfluencesthechangeofbronchomotortone,e.g.depthof
anaesthesia,drugsandvariousproceduresonairway,respiratorydiseases(bronchialasthma)andinhalational
agents.Usingcomputedtomography,Brownetal.hadshowedthathalothanecausesgreaterbronchodilatation
thanisofluraneatlowconcentrations.[49]Sevoflurane(1minimumalveolarconcentration)reducedrespiratory
systemresistance(determinedusinganisovolumetechnique)by15%inpatientsundergoingelectivesurgery.In
contrast,desfluranedidnotsignificantlyalterresistance.[50]

SUMMARY Goto:

Clinicalapplicationoftheanatomicalknowledgeofrespiratorysystemdefinitelyimprovessafetyofconductof
anaesthesiaandalsooptimisespatientventilatoryconditionandairwaypatency.Suchknowledgehasinfluenceon
theclinicalpracticeofairwaymanagement,lungisolationduringanaesthesia,managementofcaseswithrespiratory
disorders,respiratoryendoluminalproceduresandsurgeries,optimisingventilatorstrategiesinperioperativeperiod,
applyingjetventilationduringemergencyandendoluminalsurgeriesanddesigningairwaydevices.

AnanaesthesiologistshouldunderstandthatFRCisthemostimportantparameter.Itsrelationwithclosingcapacity
isanimportantdeterminantofventilationofpatient.Ventilationandperfusionbothareaffectedbythegravity.
Overallventilationtoperfusionratiois1butitalterswithanaesthesia,bodypositionsandwithonelung
anaesthesia.HPV,animportantsafetymechanism,isinhibitedbymajorityofanaestheticdrugs.Ventilation
perfusionmismatchleadingtoreducedarterialoxygenconcentrationismainlybecauseofearlyclosureofairway
leadingtodecreasedventilationandatelectasisoccurringwiththeanaesthesia.Variousanaestheticdrugsalter
neuronalcontrolofthebreathingandbronchomotortone.

Financialsupportandsponsorship
Nil.

Conflictsofinterest
Therearenoconflictsofinterest.

REFERENCES Goto:

1.DrainCB.Physiologyofrespiratorysystemrelatedtoanesthesia.CRNA.19967:16380.[PubMed]

2.BrismarB,HedenstiernaG,LundquistH,StrandbergA,SvenssonL,TokicsL.Pulmonarydensitiesduring
anesthesiawithmuscularrelaxationAproposalofatelectasis.Anesthesiology.198562:4228.[PubMed]

3.HedenstiernaG.Gasexchangeduringanaesthesia.ActaAnaesthesiolScandSuppl.199094:2731.[PubMed]

4.AhmedNusrathA,TongJL,SmithJE.Pathwaysthroughthenosefornasalintubation:Acomparisonofthree
endotrachealtubes.BrJAnaesth.2008100:26974.[PubMed]

5.WatanabeT,IsonoS,TanakaA,TanzawaH,NishinoT.Contributionofbodyhabitusandcraniofacial
characteristicstosegmentalclosingpressuresofthepassivepharynxinpatientswithsleepdisorderedbreathing.
AmJRespirCritCareMed.2002165:2605.[PubMed]

6.ShortenGD,OpieNJ,GraziottiP,MorrisI,KhangureM.Assessmentofupperairwayanatomyinawake,
sedatedandanaesthetisedpatientsusingmagneticresonanceimaging.AnaesthIntensiveCare.199422:1659.
[PubMed]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613399/ 7/10
2/13/2017 Anatomyandphysiologyofrespiratorysystemrelevanttoanaesthesia

7.BenumofJL.Obstructivesleepapneaintheadultobesepatient:Implicationsforairwaymanagement.
AnesthesiolClinNorthAmerica.200220:789811.[PubMed]

8.ChouHC,WuTL.Largehypopharyngealtongue:Asharedanatomicabnormalityfordifficultmaskventilation,
difficultintubation,andobstructivesleepapnea?Anesthesiology.200194:9367.[PubMed]

9.IsonoS.Obesityandobstructivesleepapnoea:Mechanismsforincreasedcollapsibilityofthepassivepharyngeal
airway.Respirology.201217:3242.[PubMed]

10.WeibelER.MorphometryoftheHumanLung.Berlin,Heidelberg:Springer1963.Geometryanddimensions
ofairwaysofconductiveandtransitoryzonespp.11035.

11.MinnichDJ,MathisenDJ.Anatomyofthetrachea,carina,andbronchi.ThoracSurgClin.200717:57185.
[PubMed]

12.WebbEM,ElickerBM,WebbWR.UsingCTtodiagnosenonneoplastictrachealabnormalities:Appearanceof
thetrachealwall.AJRAmJRoentgenol.2000174:131521.[PubMed]

13.UgaldeP,MiroS,FrchetteE,DeslauriersJ.Correlativeanatomyforthoracicinletglottisandsubglottis
trachea,carina,andmainbronchilobes,fissures,andsegmentshilumandpulmonaryvascularsystembronchial
arteriesandlymphatics.ThoracSurgClin.200717:63959.[PubMed]

14.EderleJR,HeusselCP,HastJ,FischerB,VanBeekEJ,LeyS,etal.Evaluationofchangesincentralairway
dimensions,lungareaandmeanlungdensityatpairedinspiratory/expiratoryhighresolutioncomputed
tomography.EurRadiol.200313:245461.[PubMed]

15.BoisellePM,ReynoldsKF,ErnstA.Multiplanarandthreedimensionalimagingofthecentralairwayswith
multidetectorCT.AJRAmJRoentgenol.2002179:3018.[PubMed]

16.KarabulutN.CTassessmentoftrachealcarinalangleanditsdeterminants.BrJRadiol.200578:78790.
[PubMed]

17.ChunderR,GuhaR.Amorphometricstudyofhumansubcarinalangleindifferentagegroupsinbothsexes
anditsclinicalimplications.IndianJBasicApplMedRes.20154:42430.

18.HaskinPH,GoodmanLR.Normaltrachealbifurcationangle:Areassessment.AJRAmJRoentgenol.
1982139:87982.[PubMed]

19.CherngCH,WongCS,HsuCH,HoST.Airwaylengthinadults:Estimationoftheoptimalendotrachealtube
lengthfororotrachealintubation.JClinAnesth.200214:2714.[PubMed]

20.BreatnachE,AbbottGC,FraserRG.Dimensionsofthenormalhumantrachea.AJRAmJRoentgenol.
1984142:9036.[PubMed]

21.BrockRC.Theanatomyofthebronchialtree.AMAArchOtolaryngol.195868:4549.[PubMed]

22.MiW,ZhangC,WangH,CaoJ,LiC,YangL,etal.Measurementandanalysisofthetracheobronchialtreein
Chinesepopulationusingcomputedtomography.PLoSOne.201510:e0123177.[PMCfreearticle][PubMed]

23.GrilloHC.Diseases,Diagnosis,ResultsofTreatment.London:BCDeckerInc2004.SurgeryoftheTrachea
andBronchipp.4351.

24.SeymourAH.Therelationshipbetweenthediametersoftheadultcricoidringandmaintracheobronchialtree:
Acadaverstudytoinvestigatethebasisfordoublelumentubeselection.JCardiothoracVascAnesth.
200317:299301.[PubMed]

25.OtochJP,MinamotoH,PeriniM,CarneiroFO,deAlmeidaArtifonEL.Isthereacorrelationbetweenright
bronchuslengthanddiameterwithage?JThoracDis.20135:3069.[PMCfreearticle][PubMed]

26.GriscomNT,WohlME.Trachealsizeandshape:Effectsofchangeinintraluminalpressure.Radiology.
1983149:2730.[PubMed]

27.WittenborgMH,GyepesMT,CrockerD.Trachealdynamicsininfantswithrespiratorydistress,stridor,and
collapsingtrachea.Radiology.196788:65362.[PubMed]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613399/ 8/10
2/13/2017 Anatomyandphysiologyofrespiratorysystemrelevanttoanaesthesia

28.AbakayA,TanrikuluAC,SenHS,AbakayO,AydinA,CarkanatAI,etal.Clinicalanddemographic
characteristicsoftracheobronchialvariations.LungIndia.201128:1803.[PMCfreearticle][PubMed]

29.GhayeB,SzapiroD,FanchampsJM.Congenitalbronchialabnormalitiesrevisited.Radiographics.
200121:10519.[PubMed]

30.HortonKM,HortonMR,FishmanEK.Advancedvisualizationofairwayswith64MDCT:3Dmappingand
virtualbronchoscopy.AJRAmJRoentgenol.2007189:138796.[PubMed]

31.SaadC,MethaA.Accessorycardiacbronchus.JBronchology.20029:3112.

32.GhayeB,SzapiroD,FanchampsJM,DondelingerRF.Congenitalbronchialabnormalitiesrevisited.
Radiographics.20011:10519.[PubMed]

33.BederS,KpeliE,KarnakD,KayacanO.TracheobronchialvariationsinTurkishpopulation.ClinAnat.
200821:5318.[PubMed]

34.KhurshidI,AndersonLC,DownieGH.Trachealaccessorylobetakeoffandquadrifurcationofrightupper
lobebronchus:Araretracheobronchialanomaly.JBronchology.200310:5860.

35.ConacherID.Implicationsofatrachealbronchusforadultanaestheticpractice.BrJAnaesth.200085:31720.
[PubMed]

36.IkenoS,MitsuhataH,SaitoK,HirabayashiY,AkazawaS,KasudaH,etal.Airwaymanagementforpatients
withatrachealbronchus.BrJAnaesth.199676:5735.[PubMed]

37.AounNY,VelezE,KenneyLA,TraynerEE.Trachealbronchus.RespirCare.200449:10568.[PubMed]

38.GhayeB,KosX,DondelingerRF.Accessorycardiacbronchus:3DCTdemonstrationinninecases.Eur
Radiol.19999:458.[PubMed]

39.KavanachB,HedenstiernaG.Respiratoryphysiologyandpathophysiology.In:MillerRD,editor.Miller's
Anesthesia.8thed.Philadelphia:Elsevier2015.pp.44472.

40.RocaJ,BurgosF,BarberJA,SunyerJ,RodriguezRoisinR,CastellsaguJ,etal.Predictionequationsfor
plethysmographiclungvolumes.RespirMed.199892:45460.[PubMed]

41.GrassinoAE,RoussosC,MacklemPT.TheLung:ScientificFoundations.2nded.NewYork:NewRaven
1997.Staticpropertiesofthelungandchestwallpp.1187202.

42.HedenstiernaG.Effectsofbodypositiononventilation/perfusionmatching.In:GulioA,editor.Anaesthesia,
Pain,IntensiveCareandEmergencyMedicineA.P.I.C.E.Milan:Springer2005.pp.315.

43.HedenstiernaG,BaehrendtzS,KlingstedtC,SantessonJ,SderborgB,DahlbornM,etal.Ventilationand
perfusionofeachlungduringdifferentialventilationwithselectivePEEP.Anesthesiology.198461:36976.
[PubMed]

44.HughesM,WestJB.Lastwordonpoint:Counterpoint:Gravityis/isnotthemajorfactordeterminingthe
distributionofbloodflowinthehumanlung.JApplPhysiol.2008104:1539.[PubMed]

45.WestJB,DolleryCT,NaimarkA.Distributionofbloodflowinisolatedlungrelationtovascularandalveolar
pressures.JApplPhysiol.196419:71324.[PubMed]

46.HughesJM,GlazierJB,MaloneyJE,WestJB.Effectoflungvolumeonthedistributionofpulmonaryblood
flowinman.RespirPhysiol.19684:5872.[PubMed]

47.RothenHU,SporreB,EngbergG,WegeniusG,HedenstiernaG.Airwayclosure,atelectasisandgasexchange
duringgeneralanaesthesia.BrJAnaesth.199881:6816.[PubMed]

48.MillsGH.Respiratoryphysiologyandanaesthesia.BrJAnesthCEPDRev.20011:359.

49.BrownRH,ZerhouniEA,HirshmanCA.Comparisonoflowconcentrationsofhalothaneandisofluraneas
bronchodilators.Anesthesiology.199378:1097101.[PubMed]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613399/ 9/10
2/13/2017 Anatomyandphysiologyofrespiratorysystemrelevanttoanaesthesia

50.GoffMJ,ArainSR,FickeDJ,UhrichTD,EbertTJ.Absenceofbronchodilationduringdesfluraneanesthesia:
Acomparisontosevofluraneandthiopental.Anesthesiology.200093:4048.[PubMed]

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